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Yabroff KR, Sylvia Shi K, Zhao J, Freedman AN, Zheng Z, Nogueira L, Han X, Klabunde CN, de Moor JS. Importance of Patient Health Insurance Coverage and Out-of-Pocket Costs for Genomic Testing in Oncologists' Treatment Decisions. JCO Oncol Pract 2024; 20:429-437. [PMID: 38194620 DOI: 10.1200/op.23.00153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 08/14/2023] [Accepted: 11/14/2023] [Indexed: 01/11/2024] Open
Abstract
PURPOSE Use of genomic testing, especially multimarker panels, is increasing in the United States. Not all tests and related treatments are covered by health insurance, which can result in substantial patient out-of-pocket (OOP) costs. Little is known about oncologists' treatment decisions with respect to patient insurance coverage and OOP costs for genomic testing. METHODS We identified 1,049 oncologists who used multimarker tumor panels from the 2017 National Survey of Precision Medicine in Cancer Treatment. Separate multivariable ordinal logistic regressions examined associations of oncologist-, practice-, and area-level characteristics and oncologists' ratings of importance (very, somewhat, or a little/not important) of insurance coverage and OOP costs for genomic testing in treatment decisions, adjusting for oncologist years of experience, sex, race and ethnicity, specialty, use of next-generation sequencing (NGS) tests, region, tumor boards, patient insurance mix, and area-level socioeconomic characteristics. RESULTS Among oncologists, 47.3%, 32.7%, and 20.0% reported that patient insurance coverage for genomic testing was very, somewhat, or a little/not important, respectively, in treatment decisions. In addition, 56.9%, 28.0%, and 15.2% reported that OOP costs for testing were very, somewhat, or a little/not important, respectively. In adjusted analyses, oncologists who used NGS tests were more likely to report patient insurance and OOP costs as important (odds ratio [OR], 2.00 [95% CI, 1.16 to 3.45] and OR, 2.12 [95% CI, 1.22 to 3.68], respectively) in treatment decisions compared with oncologists who did not use these tests, as were oncologists who treated solid tumors, rather than only hematological cancers. More years of experience and higher percentages of Medicaid or self-paid/uninsured patients in the practice were associated with reporting insurance coverage (OR, 1.43 [95% CI, 1.09 to 1.89]) and OOP costs (OR, 1.51 [95% CI, 1.13 to 2.01]) as important. Oncologists in practices with molecular tumor boards for genomic tests were less likely to report coverage (OR, 0.63 [95% CI, 0.47 to 0.85]) and OOP costs (OR, 0.72 [95% CI, 0.53 to 0.97]) as important than their counterparts in practices without these tumor boards. CONCLUSION Most oncologists rate patient health insurance and OOP costs for genomic tests as important considerations in subsequent treatment recommendations. Modifiable factors associated with these ratings can inform interventions to support patient-physician decision making about care.
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Affiliation(s)
- K Robin Yabroff
- Surveillance and Health Equity Science, American Cancer Society, Atlanta, GA
| | - Kewei Sylvia Shi
- Surveillance and Health Equity Science, American Cancer Society, Atlanta, GA
| | - Jingxuan Zhao
- Surveillance and Health Equity Science, American Cancer Society, Atlanta, GA
| | - Andrew N Freedman
- Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, MD
| | - Zhiyuan Zheng
- Surveillance and Health Equity Science, American Cancer Society, Atlanta, GA
| | - Leticia Nogueira
- Surveillance and Health Equity Science, American Cancer Society, Atlanta, GA
| | - Xuesong Han
- Surveillance and Health Equity Science, American Cancer Society, Atlanta, GA
| | - Carrie N Klabunde
- Office of Disease Prevention, Office of the Director, National Institutes of Health, Rockville, MD
| | - Janet S de Moor
- Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, MD
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2
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Pereyra L, Schlottmann F, Steinberg L, Lasa J. Colorectal Cancer Prevention: Is Chat Generative Pretrained Transformer (Chat GPT) ready to Assist Physicians in Determining Appropriate Screening and Surveillance Recommendations? J Clin Gastroenterol 2024:00004836-990000000-00265. [PMID: 38319619 DOI: 10.1097/mcg.0000000000001979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 01/12/2024] [Indexed: 02/07/2024]
Abstract
OBJECTIVE To determine whether a publicly available advanced language model could help determine appropriate colorectal cancer (CRC) screening and surveillance recommendations. BACKGROUND Poor physician knowledge or inability to accurately recall recommendations might affect adherence to CRC screening guidelines. Adoption of newer technologies can help improve the delivery of such preventive care services. METHODS An assessment with 10 multiple choice questions, including 5 CRC screening and 5 CRC surveillance clinical vignettes, was inputted into chat generative pretrained transformer (ChatGPT) 3.5 in 4 separate sessions. Responses were recorded and screened for accuracy to determine the reliability of this tool. The mean number of correct answers was then compared against a control group of gastroenterologists and colorectal surgeons answering the same questions with and without the help of a previously validated CRC screening mobile app. RESULTS The average overall performance of ChatGPT was 45%. The mean number of correct answers was 2.75 (95% CI: 2.26-3.24), 1.75 (95% CI: 1.26-2.24), and 4.5 (95% CI: 3.93-5.07) for screening, surveillance, and total questions, respectively. ChatGPT showed inconsistency and gave a different answer in 4 questions among the different sessions. A total of 238 physicians also responded to the assessment; 123 (51.7%) without and 115 (48.3%) with the mobile app. The mean number of total correct answers of ChatGPT was significantly lower than those of physicians without [5.62 (95% CI: 5.32-5.92)] and with the mobile app [7.71 (95% CI: 7.39-8.03); P < 0.001]. CONCLUSIONS Large language models developed with artificial intelligence require further refinements to serve as reliable assistants in clinical practice.
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Affiliation(s)
- Lisandro Pereyra
- Department of Gastroenterology
- Endoscopy Unit, Department of Surgery
| | - Francisco Schlottmann
- Endoscopy Unit, Department of Surgery
- Department of Surgery, Hospital Alemán of Buenos Aires
| | - Leandro Steinberg
- Department of Gastroenterology, Fundacion Favaloro, Buenos Aires, Argentina
| | - Juan Lasa
- Department of Gastroenterology, CEMIC, Buenos Aires, Argentina
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3
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Prenatt Z, Liaquat H, Lovett T, Evans J, Srivilli M, Marzotto N, Martins N. Impact of Epic Smartlist and Lumens Software in Improving OP-29 Compliance at a Tertiary Health Care Network. Cureus 2023; 15:e40193. [PMID: 37431362 PMCID: PMC10329865 DOI: 10.7759/cureus.40193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/09/2023] [Indexed: 07/12/2023] Open
Abstract
Background OP-29 is a Centers for Medicaid and Medicare Services (CMS) measure to ensure that endoscopists recommend appropriate follow-up intervals after normal colonoscopy in average risk patients. Failure to report OP-29 compliance can adversely affect hospital quality star rating as well as reimbursement for health care. The aim of our quality improvement project was to improve OP-29 compliance to the top decile over three years. Methodology Our sample included patients between 50-75 years of age who received average risk screening colonoscopies with normal findings. We provided intensive education to endoscopists about the importance of OP-29 compliance, developed an Epic Smartlist that directs our endoscopists to list an appropriate reason for colonoscopy intervals other than 10 years, and monitored OP-29 compliance monthly. We became the first health network in the United States to implement the Lumens endoscopy report writing software (Epic Systems Corporation, Verona, USA) and added the OP-29-related Epic Smartlist to the Lumens colonoscopy note template. All statistical analyses were conducted in SPSS version 26 (IBM Corp., Armonk, USA) to compute the means and frequencies of outcomes. Results Our sample included 2,171 patients with a mean age of 60.5 years of whom the majority were female (57.2%) and Caucasians (90%). Our OP-29 score increased from 87.47% to 100% over the course of three years, and this steady improvement was seen broadly across our network. We compared our network score averages to our state and national averages and consistently demonstrated higher compliance rates while reaching the top decile by 2020. Conclusion We believe our improved OP-29 compliance has reduced colonoscopy overutilization, improved health care quality, and reduced health care costs for our patients and health network. To our knowledge, this is the first reported project towards improving OP-29 compliance utilizing the Epic Lumens software. Epic Lumens (Epic Systems Corporation, Verona, USA) added this Smartlist as quick buttons in the standard colonoscopy procedure note templates they built for other organizations to improve health care quality and cost nationally.
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Affiliation(s)
- Zarian Prenatt
- Internal Medicine, St. Luke's University Health Network, Bethlehem, USA
| | - Hammad Liaquat
- Gastroenterology, St. Luke's University Health Network, Bethlehem, USA
| | - Troy Lovett
- Medical School, Lewis Katz School of Medicine at Temple, St. Luke's University Health Network, Bethlehem, USA
| | - Joseph Evans
- Medical School, Lewis Katz School of Medicine at Temple, St. Luke's University Health Network, Bethlehem, USA
| | - Manasa Srivilli
- Medical School, Lewis Katz School of Medicine at Temple, St. Luke's University Health Network, Bethlehem, USA
| | - Nicholas Marzotto
- Product Management - Epic Lumens, St. Luke's University Health Network, Bethlehem, USA
| | - Noel Martins
- Gastroenterology, St. Luke's University Health Network, Bethlehem, USA
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4
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Rintala S, Dahlstrom KR, Franco EL, Louvanto K. A synthesis of evidence for cancer-specific screening interventions: A Preventive Medicine Golden Jubilee Review. Prev Med 2023; 167:107395. [PMID: 36565859 DOI: 10.1016/j.ypmed.2022.107395] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 12/15/2022] [Accepted: 12/17/2022] [Indexed: 12/24/2022]
Abstract
The goal of cancer screening guidelines is to inform health practitioners to practice evidence-based cancer prevention. Cancer screening aims to detect treatable precancerous lesions or early-stage disease to enable actions aimed at decreasing morbidity and mortality. Continuous assessment of the available evidence for or against screening interventions by various organizations often results in conflicting recommendations and create challenges for providers and policymakers. Here we have summarized the current cancer screening recommendations by five leading organizations in North America and Europe: the National Cancer Institute's Physician Data Query (PDQ), the U.S. Preventive Services Task Force (USPSTF), the Canadian Task Force on Preventive Health Care (CTFPHC), the Cochrane Database of Systematic Reviews (CDSR), and the UK National Screening Committee for the National Health Service (UK NSC). All organizations assess evidence based on strength, quality, and quantity, and recommendations are similar although with differences with respect to screening start and stop ages. Recommendations are consistent for colorectal cancer screening with fecal occult blood test or fecal immunochemical test, cervical cancer screening with Pap-test, HPV-test, or co-testing, and breast cancer screening with mammography. However, guidelines vary with respect to age to start and end screening and testing frequency. Tests that have proven to be inefficient or whose use is capable of causing harm are routinely recommended against. Continuous review of screening guidelines is necessary to evaluate the many promising screening tests currently under investigation.
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Affiliation(s)
- Suvi Rintala
- Department of Obstetrics and Gynecology, Faculty of Medicine and Health Technology, Tampere University, Finn-Medi1, Biokatu 6, 33100 Tampere, Finland.
| | - Kristina R Dahlstrom
- Section of Epidemiology & Population Sciences, Department of Medicine, Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030, USA.
| | - Eduardo L Franco
- Division of Cancer Epidemiology, McGill University, 5100 Maisonneuve Blvd West, Suite 720, Montreal, Quebec H4A 3T2, Canada.
| | - Karolina Louvanto
- Department of Obstetrics and Gynecology, Faculty of Medicine and Health Technology, Tampere University, Finn-Medi1, Biokatu 6, 33100 Tampere, Finland; Department of Obstetrics and Gynecology, Tampere University Hospital, Elämänaukio 2, 33520 Tampere, Finland.
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5
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Shafer LA, Restall G, Simms A, Lee E, Park J, Singh H. Clinician based decision tool to guide recommended interval between colonoscopies: development and evaluation pilot study. BMC Med Inform Decis Mak 2022; 22:136. [PMID: 35581662 PMCID: PMC9112638 DOI: 10.1186/s12911-022-01872-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 05/04/2022] [Indexed: 11/13/2022] Open
Abstract
Background Optimal intervals between repeat colonoscopies could improve patient outcomes and reduce costs. We evaluated: (a) concordance between clinician and guideline recommended colonoscopy screening intervals in Winnipeg, Manitoba, (b) clinician opinions about the utility of an electronic decision-making tool to aid in recommending screening intervals, and (c) the initial use of a decision-making smartphone/web-based application. Methods Clinician endoscopists and primary care providers participated in four focus groups (N = 22). We asked participating clinicians to evaluate up to 12 hypothetical scenarios and compared their recommended screening interval to those of North American guidelines. Fisher’s exact tests were used to assess differences in agreement with guidelines. We developed a decision-making tool and evaluated it via a pilot study with 6 endoscopists. Result 53% of clinicians made recommendations that agreed with guidelines in ≤ 50% of the hypothetical scenarios. Themes from focus groups included barriers to using a decision-making tool: extra time to use it, less confidence in the results of the tool over their own judgement, and having access to the information required by the tool (e.g., family history). Most were willing to try a tool if it was quick and easy to use. Endoscopists participating in the tool pilot study recommended screening intervals discordant with guidelines 35% of the time. When their recommendation differed from that of the tool, they usually endorsed their own over the guideline. Conclusions Endoscopists are overconfident and inconsistent with applying guidelines in their polyp surveillance interval recommendations. Use of a decision tool may improve knowledge and application of guidelines. A change in practice may require that the tool be coupled with continuing education about evidence for improved outcomes if guidelines are followed. Supplementary Information The online version contains supplementary material available at 10.1186/s12911-022-01872-z.
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Affiliation(s)
- Leigh Anne Shafer
- Section of Gastroenterology, Department of Internal Medicine, Rady Faculty of Health Sciences, University of Manitoba, 805-715 McDermot Avenue, Winnipeg, MB, R3E3P4, Canada.,Department of Community Health Sciences, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Gayle Restall
- Department of Occupational Therapy, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Alexandria Simms
- Department of Occupational Therapy, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Eugene Lee
- Section of Gastroenterology, Department of Internal Medicine, Rady Faculty of Health Sciences, University of Manitoba, 805-715 McDermot Avenue, Winnipeg, MB, R3E3P4, Canada
| | - Jason Park
- Section of Gastroenterology, Department of Internal Medicine, Rady Faculty of Health Sciences, University of Manitoba, 805-715 McDermot Avenue, Winnipeg, MB, R3E3P4, Canada.,CancerCare Manitoba Research Institute, Winnipeg, MB, Canada
| | - Harminder Singh
- Section of Gastroenterology, Department of Internal Medicine, Rady Faculty of Health Sciences, University of Manitoba, 805-715 McDermot Avenue, Winnipeg, MB, R3E3P4, Canada. .,Department of Community Health Sciences, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada. .,CancerCare Manitoba Research Institute, Winnipeg, MB, Canada.
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6
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Zhu X, Weiser E, Jacobson DJ, Griffin JM, Limburg PJ, Finney Rutten LJ. Factors Associated With Clinician Recommendations for Colorectal Cancer Screening Among Average-Risk Patients: Data From a National Survey. Prev Chronic Dis 2022; 19:E19. [PMID: 35420980 PMCID: PMC9044901 DOI: 10.5888/pcd19.210315] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Introduction Colorectal cancer (CRC) screening among average-risk patients is underused in the US. Clinician recommendation is strongly associated with CRC screening completion. To inform interventions that improve CRC screening uptake among average-risk patients, we examined clinicians’ routine recommendations of 7 guideline-recommended screening methods and factors associated with these recommendations. Methods We conducted an online survey in November and December 2019 among a sample of primary care clinicians (PCCs) and gastroenterologists (GIs) from a panel of US clinicians. Clinicians reported whether they routinely recommend each screening method, screening method intervals, and patient age at which they stop recommending screening. We also measured the influence of various factors on screening recommendations. Results Nearly all 814 PCCs (99%) and all 159 GIs (100%) reported that they routinely recommend colonoscopy for average-risk patients, followed by stool-based tests (more than two-thirds of PCCs and GIs). Recommendation of other visualization-based methods was less frequent (PCCs, 26%–35%; GIs, 30%–41%). A sizable proportion of clinicians reported guideline-discordant screening intervals and age to stop screening. Guidelines and clinical evidence were most frequently reported as very influential to clinician recommendations. Factors associated with routine recommendation of each screening method included clinician-perceived effectiveness of the method, clinician familiarity with the method, Medicare coverage, clinical capacity, and patient adherence. Conclusion Clinician education is needed to improve knowledge, familiarity, and experience with guideline-recommended screening methods with the goal of effectively engaging patients in informed decision making for CRC screening.
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Affiliation(s)
- Xuan Zhu
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
| | | | - Debra J. Jacobson
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, Minnesota
| | - Joan M. Griffin
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
- Division of Health Care Delivery Research, Mayo Clinic, Rochester, Minnesota
| | - Paul J. Limburg
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
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Gerber DE, Hamann HA, Dorsey O, Ahn C, Phillips JL, Santini NO, Browning T, Ochoa CD, Adesina J, Natchimuthu VS, Steen E, Majeed H, Gonugunta A, Lee SJC. Clinician Variation in Ordering and Completion of Low-Dose Computed Tomography for Lung Cancer Screening in a Safety-Net Medical System. Clin Lung Cancer 2020; 22:e612-e620. [PMID: 33478912 DOI: 10.1016/j.cllc.2020.12.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Revised: 11/19/2020] [Accepted: 12/01/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Less than 5% of eligible individuals in the United States undergo lung cancer screening. Variation in clinicians' participation in lung cancer screening has not been determined. PATIENTS AND METHODS We studied medical providers who ordered ≥ 1 low-dose computed tomography (LDCT) for lung cancer screening from February 2017 through February 2019 in an integrated safety-net healthcare system. We analyzed associations between provider characteristics and LDCT orders and completion using chi-square, Fisher exact, and Student t tests, as well as ANOVA and multinomial logistic regression. RESULTS Among an estimated 194 adult primary care physicians, 144 (74%) ordered at least 1 LDCT, as did 39 specialists. These 183 medical providers ordered 1594 LDCT (median, 4; interquartile range, 2-9). In univariate and multivariate models, family practice providers (P < .001) and providers aged ≥ 50 years (P = .03) ordered more LDCT than did other clinicians. Across providers, the median proportion of ordered LDCT that were completed was 67%. The total or preceding number of LDCT ordered by a clinician was not associated with the likelihood of LDCT completion. CONCLUSION In an integrated safety-net healthcare system, most adult primary care providers order LDCT. The number of LDCT ordered varies widely among clinicians, and a substantial proportion of ordered LDCT are not completed.
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Affiliation(s)
- David E Gerber
- Department of Population and Data Sciences, UT Southwestern Medical Center, Dallas, TX; Division of Hematology-Oncology, UT Southwestern Medical Center, Dallas, TX; Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, TX.
| | - Heidi A Hamann
- Departments of Psychology and Family and Community Medicine, University of Arizona, Tucson, AZ
| | - Olivia Dorsey
- Department of Population and Data Sciences, UT Southwestern Medical Center, Dallas, TX
| | - Chul Ahn
- Department of Population and Data Sciences, UT Southwestern Medical Center, Dallas, TX; Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, TX
| | - Jessica L Phillips
- Department of Population and Data Sciences, UT Southwestern Medical Center, Dallas, TX
| | - Noel O Santini
- Parkland Health and Hospital System, Dallas, TX; Division of General Internal Medicine, UT Southwestern Medical Center, Dallas, TX
| | - Travis Browning
- Parkland Health and Hospital System, Dallas, TX; Department of Radiology, UT Southwestern Medical Center, Dallas, TX
| | - Cristhiaan D Ochoa
- Parkland Health and Hospital System, Dallas, TX; Division of Pulmonary and Critical Care Medicine, UT Southwestern Medical Center, Dallas, TX
| | | | | | - Eric Steen
- Parkland Health and Hospital System, Dallas, TX; Division of General Internal Medicine, UT Southwestern Medical Center, Dallas, TX
| | - Harris Majeed
- School of Medicine, UT Southwestern Medical Center, Dallas, TX
| | - Amrit Gonugunta
- School of Medicine, UT Southwestern Medical Center, Dallas, TX
| | - Simon J Craddock Lee
- Department of Population and Data Sciences, UT Southwestern Medical Center, Dallas, TX; Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, TX
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8
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Karwa A, Patell R, Parthasarathy G, Lopez R, McMichael J, Burke CA. Development of an Automated Algorithm to Generate Guideline-based Recommendations for Follow-up Colonoscopy. Clin Gastroenterol Hepatol 2020; 18:2038-2045.e1. [PMID: 31622739 DOI: 10.1016/j.cgh.2019.10.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Revised: 09/22/2019] [Accepted: 10/04/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Physician adherence to published colonoscopy surveillance guidelines varies. We aimed to develop and validate an automated clinical decision support algorithm that can extract procedure and pathology data from the electronic medical record (EMR) and generate surveillance intervals congruent with guidelines, which might increase physician adherence. METHODS We constructed a clinical decision support (CDS) algorithm based on guidelines from the United States Multi-Society Task Force on Colorectal Cancer. We used a randomly generated validation dataset of 300 outpatient colonoscopies performed at the Cleveland Clinic from 2012 through 2016 to evaluate the accuracy of extracting data from reports stored in the EMR using natural language processing (NLP). We compared colonoscopy follow-up recommendations from the CDS algorithm, endoscopists, and task force guidelines. Using a testing dataset of 2439 colonoscopies, we compared endoscopist recommendations with those of the algorithm. RESULTS Manual review of the validation dataset confirmed the NLP program accurately extracted procedure and pathology data for all cases. Recommendations made by endoscopists and the CDS algorithm were guideline-concordant in 62% and 99% of cases, respectively. Discrepant recommendations by endoscopists were earlier than recommended in 94% of the cases. In the testing dataset, 69% of endoscopist and NLP-CDS algorithm recommendations were concordant. Discrepant recommendations by endoscopists were earlier than guidelines in 91% of cases. CONCLUSIONS We constructed and tested an automated CDS algorithm that can use NLP-extracted data from the EMR to generate follow-up colonoscopy surveillance recommendations based on published guidelines.
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Affiliation(s)
- Abhishek Karwa
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Rushad Patell
- Department of Hematology Oncology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | | | - Rocio Lopez
- Center for Populations Health Research, Cleveland Clinic, Cleveland, Ohio
| | - John McMichael
- Department of General Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Carol A Burke
- Department of Gastroenterology, Hepatology and Nutrition, Cleveland Clinic, Cleveland, Ohio.
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9
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Ghai NR, Jensen CD, Merchant SA, Schottinger JE, Lee JK, Chubak J, Kamineni A, Halm EA, Skinner CS, Haas JS, Green BB, Cannizzaro NT, Schneider JL, Corley DA. Primary Care Provider Beliefs and Recommendations About Colorectal Cancer Screening in Four Healthcare Systems. Cancer Prev Res (Phila) 2020; 13:947-958. [PMID: 32669318 DOI: 10.1158/1940-6207.capr-20-0109] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 06/01/2020] [Accepted: 07/08/2020] [Indexed: 12/31/2022]
Abstract
Primary care provider's (PCP) perceptions of colorectal cancer screening test effectiveness and their recommendations for testing intervals influence patient screening uptake. Few large studies have examined providers' perceptions and recommendations, including their alignment with evidence suggesting comparable test effectiveness and guideline recommendations for screening frequency. Providers (n = 1,281) within four healthcare systems completed a survey in 2017-2018 regarding their perceptions of test effectiveness and recommended intervals for colonoscopy and fecal immunochemical testing (FIT) for patients ages 40-49, 50-74, and ≥75 years. For patients 50-74 (screening eligible), 82.9% of providers rated colonoscopy as very effective versus 59.6% for FIT, and 26.3% rated colonoscopy as more effective than FIT. Also, for this age group, 77.9% recommended colonoscopy every 10 years and 92.4% recommended FIT annually. For patients ages 40-49 and ≥75, more than one-third of providers believed the tests were somewhat or very effective, although >80% did not routinely recommend screening by either test for these age groups. Provider screening test interval recommendations generally aligned with colorectal cancer guidelines; however, 25% of providers believed colonoscopy was more effective than FIT for mortality reduction, which differs from some modeling studies that suggest comparable effectiveness. The latter finding may have implications for health systems where FIT is the dominant screening strategy. Only one-third of providers reported believing these screening tests were effective in younger and older patients (i.e., <50 and ≥75 years). Evidence addressing these beliefs may be relevant if cancer screening recommendations are modified to include older and/or younger patients.
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Affiliation(s)
- Nirupa R Ghai
- Department of Patient Care Services, Kaiser Permanente Southern California, Pasadena, CA.
| | | | - Sophie A Merchant
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Joanne E Schottinger
- Department of Quality and Clinical Analysis, Kaiser Permanente Southern California, Pasadena, CA
| | - Jeffrey K Lee
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Jessica Chubak
- Kaiser Permanente Washington Health Research Institute, Kaiser Permanente Washington, Seattle, WA
| | - Aruna Kamineni
- Kaiser Permanente Washington Health Research Institute, Kaiser Permanente Washington, Seattle, WA
| | - Ethan A Halm
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX.,Simmons Comprehensive Cancer Center and Department of Population & Data Sciences, University of Texas Southwestern Medical Center, Dallas, TX
| | - Celette Sugg Skinner
- Simmons Comprehensive Cancer Center and Department of Population & Data Sciences, University of Texas Southwestern Medical Center, Dallas, TX
| | - Jennifer S Haas
- Division of General Internal Medicine, Massachusetts General Hospital, Harvard Medical School, Dana Farber Harvard Cancer Institute, Harvard School of Public Health, Boston, MA
| | - Beverly B Green
- Kaiser Permanente Washington Health Research Institute, Kaiser Permanente Washington, Seattle, WA
| | - Nancy T Cannizzaro
- Department Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | | | - Douglas A Corley
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
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10
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Kolb JM, Molmenti CL, Patel SG, Lieberman DA, Ahnen DJ. Increased Risk of Colorectal Cancer Tied to Advanced Colorectal Polyps: An Untapped Opportunity to Screen First-Degree Relatives and Decrease Cancer Burden. Am J Gastroenterol 2020; 115:980-988. [PMID: 32618646 PMCID: PMC9351033 DOI: 10.14309/ajg.0000000000000639] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Advanced adenomas represent a subset of colorectal polyps that are known to confer an increased risk of colorectal neoplasia to the affected individual and their first-degree relatives (FDRs). Accordingly, professional guidelines suggest earlier and more intensive screening for FDRs of those with advanced adenomas similar to FDRs of those with colorectal cancer (CRC). Although the risk to family members is less clear among patients with advanced serrated polyps, they are often considered in the same category. Unfortunately, there is a growing concern that patients, endoscopists, and primary care providers are unaware of the familial risk associated with these polyps, leaving a wide gap in screening these high-risk individuals. Herein, we propose a standardized language around advanced colorectal polyps and present a detailed review of the literature on associated familial risk. We outline the challenges to implementing the current screening recommendations and suggest approaches to overcome these limitations, including a proposed new colonoscopy quality metric to capture communication of familial CRC risk. Improving screening in these high-risk groups has the potential to substantially reduce the burden of CRC.
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Affiliation(s)
- Jennifer M. Kolb
- Division of Gastroenterology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Christine L. Molmenti
- Department of Occupational, Medicine, Epidemiology, and Prevention, Center for Health Innovations and Outcomes Research, Feinstein Institute for Medical Research, Hofstra/Northwell School of Medicine, Northwell Health, Manhasset, New York, USA
| | - Swati G. Patel
- Division of Gastroenterology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
- Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, Colorado, USA
| | - David A. Lieberman
- Division of Gastroenterology and Hepatology, Oregon Health and Science University, Portland, Oregon, USA
- Portland Veterans Affairs Medical Center, Portland, Oregon, USA
| | - Dennis J. Ahnen
- Division of Gastroenterology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
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11
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Yabroff KR, Zhao J, de Moor JS, Sineshaw HM, Freedman AN, Zheng Z, Han X, Rai A, Klabunde CN. Factors Associated With Oncologist Discussions of the Costs of Genomic Testing and Related Treatments. J Natl Cancer Inst 2020; 112:498-506. [PMID: 31675070 PMCID: PMC7225678 DOI: 10.1093/jnci/djz173] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Revised: 07/31/2019] [Accepted: 09/04/2019] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Use of genomic testing is increasing in the United States. Testing can be expensive, and not all tests and related treatments are covered by health insurance. Little is known about how often oncologists discuss costs of testing and treatment or about the factors associated with those discussions. METHODS We identified 1220 oncologists who reported discussing genomic testing with their cancer patients from the 2017 National Survey of Precision Medicine in Cancer Treatment. Multivariable polytomous logistic regression analyses were used to assess associations between oncologist and practice characteristics and the frequency of cost discussions. All statistical tests were two-sided. RESULTS Among oncologists who discussed genomic testing with patients, 50.0% reported often discussing the likely costs of testing and related treatments, 26.3% reported sometimes discussing costs, and 23.7% reported never or rarely discussing costs. In adjusted analyses, oncologists with training in genomic testing or working in practices with electronic medical record alerts for genomic tests were more likely to have cost discussions sometimes (odds ratio [OR] = 2.09, 95% confidence interval [CI] = 1.19 to 3.69) or often (OR = 2.22, 95% CI = 1.30 to 3.79), respectively, compared to rarely or never. Other factors statistically significantly associated with more frequent cost discussions included treating solid tumors (rather than only hematological cancers), using next-generation sequencing gene panel tests, having higher patient volume, and working in practices with higher percentages of patients insured by Medicaid, or self-paid or uninsured. CONCLUSIONS Interventions targeting modifiable oncologist and practice factors, such as training in genomic testing and use of electronic medical record alerts, may help improve cost discussions about genomic testing and related treatments.
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Affiliation(s)
- K Robin Yabroff
- Surveillance and Health Services Research, American Cancer Society, Atlanta, GA
| | - Jingxuan Zhao
- Surveillance and Health Services Research, American Cancer Society, Atlanta, GA
| | | | - Helmneh M Sineshaw
- Surveillance and Health Services Research, American Cancer Society, Atlanta, GA
| | | | - Zhiyuan Zheng
- Surveillance and Health Services Research, American Cancer Society, Atlanta, GA
| | - Xuesong Han
- Surveillance and Health Services Research, American Cancer Society, Atlanta, GA
| | - Ashish Rai
- Surveillance and Health Services Research, American Cancer Society, Atlanta, GA
| | - Carrie N Klabunde
- National Cancer Institute, and Office of Disease Prevention, Office of the Director, National Institutes of Health, Bethesda, MD
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12
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Dresios C, Rachiotis G, Symvoulakis EK, Rousou X, Papagiannis D, Mouchtouri V, Hadjichristodoulou C. Nationwide Epidemiological Study of Knowledge, Attitudes, and Practices Study of Greek General Practitioners Related to Screening. Int J Prev Med 2019; 10:199. [PMID: 31772731 PMCID: PMC6868648 DOI: 10.4103/ijpvm.ijpvm_46_17] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Accepted: 02/26/2018] [Indexed: 01/17/2023] Open
Abstract
Background: We aimed to assess general practitioners’ (GPs) knowledge, attitudes, and practices (KAPs) toward screening recommendation guidelines of the United States Preventive Services Task Force (USPSTF). Methods: The survey was conducted during a 6-month period in a stratified random sample of GPs, drawn from a national database of GPs in Greece. Participants were queried about their knowledge, attitudes, and self-reported practice patterns regarding screening in a primary care setting. Sociodemographic characteristics associated with vague screening practicing were identified using multivariable logistic regression models. Results: A total of 299 participants agreed and underwent telephonic survey (response rate: 78.2%). GPs agreed on the key role of population-based screening in improving patient care, and nine out of ten reported that their performance would be improved with the adoption of computer-based support systems in clinical practice. GPs, older than 50 years of age, those who those practicing for more than 15 years and GPs working in private sector, were less likely to comply with screening recommendations. Latent class analysis revealed that male physicians and those working in public sector were more likely to comply with USPSTF recommendations. Conclusions: Our findings highlight the need of educational intervention programs for GPs in order to promote the implementation of national evidence-based screening recommendation statements in clinical practice.
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Affiliation(s)
- Christos Dresios
- Department of Hygiene and Epidemiology, Faculty of Medicine, University of Thessaly, Larissa, Greece
| | - George Rachiotis
- Department of Hygiene and Epidemiology, Faculty of Medicine, University of Thessaly, Larissa, Greece
| | | | - Xanthi Rousou
- Department of Hygiene and Epidemiology, Faculty of Medicine, University of Thessaly, Larissa, Greece
| | - Dimitrios Papagiannis
- Department of Hygiene and Epidemiology, Faculty of Medicine, University of Thessaly, Larissa, Greece
| | - Varvara Mouchtouri
- Department of Hygiene and Epidemiology, Faculty of Medicine, University of Thessaly, Larissa, Greece
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13
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Panje CM, Glatzer M, Sirén C, Plasswilm L, Putora PM. Treatment Options in Oncology. JCO Clin Cancer Inform 2019; 2:1-10. [PMID: 30652608 DOI: 10.1200/cci.18.00017] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Multiple treatment strategies exist for many oncologic problems. In this review, we provide a summary of various reasons for the existence of multiple treatment options in oncology, including factors that concern the treating physician (eg, treatment preferences), environmental factors (eg, financial, regulatory, and scientific aspects), and individual patient-specific factors (eg, medical condition, preferences). We demonstrate the vital role of available treatment options and their origins for clinical decision making and patient communication. These aspects are particularly helpful in the process of shared decision making, which is increasingly favored in situations where there are multiple medically reasonable options.
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Affiliation(s)
- Cédric M Panje
- Cédric M. Panje, Markus Glatzer, Ludwig Plasswilm, and Paul M. Putora, Kantonsspital St Gallen; Charlotta Sirén, Institute of Technology Management, University of St Gallen, St Gallen; and Ludwig Plasswilm and Paul M. Putora, University of Bern, Bern, Switzerland
| | - Markus Glatzer
- Cédric M. Panje, Markus Glatzer, Ludwig Plasswilm, and Paul M. Putora, Kantonsspital St Gallen; Charlotta Sirén, Institute of Technology Management, University of St Gallen, St Gallen; and Ludwig Plasswilm and Paul M. Putora, University of Bern, Bern, Switzerland
| | - Charlotta Sirén
- Cédric M. Panje, Markus Glatzer, Ludwig Plasswilm, and Paul M. Putora, Kantonsspital St Gallen; Charlotta Sirén, Institute of Technology Management, University of St Gallen, St Gallen; and Ludwig Plasswilm and Paul M. Putora, University of Bern, Bern, Switzerland
| | - Ludwig Plasswilm
- Cédric M. Panje, Markus Glatzer, Ludwig Plasswilm, and Paul M. Putora, Kantonsspital St Gallen; Charlotta Sirén, Institute of Technology Management, University of St Gallen, St Gallen; and Ludwig Plasswilm and Paul M. Putora, University of Bern, Bern, Switzerland
| | - Paul M Putora
- Cédric M. Panje, Markus Glatzer, Ludwig Plasswilm, and Paul M. Putora, Kantonsspital St Gallen; Charlotta Sirén, Institute of Technology Management, University of St Gallen, St Gallen; and Ludwig Plasswilm and Paul M. Putora, University of Bern, Bern, Switzerland
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14
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Highlighting a Common Quality of Care Delivery Problem: Overuse of Low-value Healthcare Services. J Healthc Qual 2019; 40:201-208. [PMID: 28846551 DOI: 10.1097/jhq.0000000000000095] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Low-value healthcare services (LVHS) are defined as procedures delivered that provide little or no clinical benefit. Overuse of LVHS, or delivery when the risks exceed the benefits, contributes to excessive spending without improved outcomes. Furthermore, overuse contributes to healthcare waste. PURPOSE The primary purpose of this commentary is to (1) examine the problem of LVHS overuse and its impacts on quality care delivery and (2) propose factors to consider in developing quality measures to help reduce overuse and waste and thus improve patient outcomes. METHODS To inform and support this commentary, we conducted a limited review of the literature related to LVHS overuse, its consequences, and suggested solutions. Online search engines were used to identify research related to our primary areas of interest. RESULTS This commentary demonstrates that overuse and associated healthcare waste is growing among selected LVHS. The factors of overuse are multidimensional and poorly understood. Meanwhile, overuse of LVHS has financial consequences and impacts quality of care and outcomes. CONCLUSIONS Overuse of LVHS is common in the United States, leading to waste and suboptimal patient outcomes. Thus a need exists to address overuse and develop measures to capture a larger scope of services.
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15
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Trainees' knowledge and application of guideline recommendations for colorectal cancer screening and surveillance. Cancer Treat Res Commun 2019; 21:100153. [PMID: 31229916 DOI: 10.1016/j.ctarc.2019.100153] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2018] [Revised: 05/30/2019] [Accepted: 06/07/2019] [Indexed: 11/22/2022]
Abstract
BACKGROUND Data shows that practicing physicians don't recommend colorectal (CRC) screening and surveillance as suggested by guidelines. We assessed knowledge of CRC guidelines in medical trainees. METHODS A survey assessing confidence and knowledge of published CRC guidelines was emailed to program directors (PDs) of Accreditation Council of Graduate Medical Education approved training programs in the United States. PDs were requested to forward it to trainees. We analyzed trainees' knowledge by answers to clinical vignettes and identification of factors required by guidelines for screening and post polypectomy colonoscopy interval. We compared confidence and knowledge by specialty. RESULTS 586 trainees in internal medicine (159), family medicine and primary care (147), gastroenterology (114), general surgery (51), ob/gyn (78), urology (13), and colorectal surgery (13) responded. 97% reported following guidelines. 68% and 50% stated confidence recalling screening and surveillance guidelines, respectively. 16% and 8% correctly identified all factors and answered corresponding vignettes for screening and surveillance, respectively. Overall accuracy of screening ranged between 11-23% and was not different between specialties (p = 0.11) while significant differences were noted between specialties in surveillance knowledge (0-39%, p < 0.001). CONCLUSIONS United States trainees' CRC screening and surveillance knowledge is poor. Measures are needed to enhance knowledge of CRC guidelines.
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16
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Simmons OL, Feng Y, Parikh ND, Singal AG. Primary Care Provider Practice Patterns and Barriers to Hepatocellular Carcinoma Surveillance. Clin Gastroenterol Hepatol 2019; 17:766-773. [PMID: 30056183 PMCID: PMC7212522 DOI: 10.1016/j.cgh.2018.07.029] [Citation(s) in RCA: 72] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Revised: 07/14/2018] [Accepted: 07/23/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Low rates of hepatocellular carcinoma (HCC) surveillance are primarily due to provider-related process failures. However, few studies have evaluated primary care provider (PCP) practice patterns, attitudes, and barriers to HCC surveillance at academic tertiary care referral centers. METHODS We conducted a web-based survey of PCPs at 2 tertiary care referral centers (133 providers) from June 2017 through December 2017. The survey was adapted from pretested surveys and included questions about practice patterns, attitudes, and barriers to HCC surveillance. We used the Fisher exact and Mann-Whitney rank-sum tests to identify factors associated with adherence to HCC surveillance recommendations, for categoric and continuous variables, respectively. RESULTS We obtained a provider-level response rate of 75% and clinic-level response rate of 100% (133 providers). Whereas most PCPs performed HCC surveillance themselves, one-third deferred surveillance to subspecialists and referred patients to a hepatology clinic. Providers believed the combination of ultrasound and α-fetoprotein analysis to be highly effective for early stage tumor detection and reported using the combination for assessment of most patients. However, PCPs were more likely to use computed tomography- or magnetic resonance imaging-based surveillance for patients with nonalcoholic steatohepatitis or decompensated cirrhosis. Most providers believed HCC surveillance to be efficacious for early tumor detection and increasing survival. However, they desired increased high-quality evidence to characterize screening benefits and harms. Providers expressed notable misconceptions about HCC surveillance, including the role for measurement of liver enzyme levels in HCC surveillance and cost effectiveness of surveillance in patients without cirrhosis. They also reported barriers, including not being up to date on HCC surveillance recommendations, limited time in the clinic, and competing clinical concerns. CONCLUSIONS In a web-based survey, PCPs reported misconceptions and barriers to HCC surveillance. This indicates the need for interventions, including provider education, to improve HCC surveillance effectiveness in clinical practice.
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Affiliation(s)
- Okeefe L. Simmons
- Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Yuan Feng
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan
| | - Neehar D. Parikh
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan
| | - Amit G. Singal
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan
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17
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Poor Knowledge of Colorectal Cancer Screening and Surveillance Guidelines in a National Cohort of Digestive Disease Specialists. Dig Dis Sci 2019; 64:391-400. [PMID: 30370490 DOI: 10.1007/s10620-018-5339-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2018] [Accepted: 10/16/2018] [Indexed: 01/02/2023]
Abstract
BACKGROUND Colorectal cancer (CRC) screening is cost-effective and prevents death from CRC if used appropriately. Physicians do not recommend CRC screening according to guidelines. Physician-related factors associated with CRC screening knowledge are unknown. AIMS We tested the accuracy of CRC screening knowledge in a nationwide cohort of practicing and trainee physicians and assessed respondent's interest in a mobile app to improve appropriate CRC screening use. METHODS An electronic survey was emailed to practicing gastroenterology professionals and medical and surgical trainees. We assessed accuracy of responses compared to CRC screening and surveillance guidelines. We assessed factors associated with higher accuracy of knowledge, frequency of workplace smartphone use, and interest in a smartphone app to aid CRC screening and surveillance recommendations. RESULTS In total, 1432 responses were received. Hundred percent accuracy was noted in 22% of respondents for screening and 37% for surveillance. Factors associated with higher accuracy of screening guidelines included more recent training completion; academic practice; performing 21-100 colonoscopies per month (vs. < 21 or > 100). Higher accuracy of surveillance guidelines was associated with more recent training completion; academic practice; being a third-year fellow. In total, 53% use smartphones at least "often" in patient care. In total, 87% would use a CRC screening and surveillance smartphone app. CONCLUSIONS Accuracy in applying CRC screening guidelines by gastroenterologists is poor. Smartphone use for patient care is prevalent. Our data show a high interest in a CRC screening/surveillance mobile app. Mobile tools appear an opportunity for rapid access and an increased adherence to CRC screening guidelines.
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18
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Neugut AI, MacLean SA, Dai WF, Jacobson JS. Physician Characteristics and Decisions Regarding Cancer Screening: A Systematic Review. Popul Health Manag 2019; 22:48-62. [DOI: 10.1089/pop.2017.0206] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Affiliation(s)
- Alfred I. Neugut
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
- Herbert Irving Comprehensive Cancer Center, College of Physicians and Surgeons, Columbia University, New York, New York
- Department of Medicine, College of Physicians and Surgeons, Columbia University, New York, New York
| | | | - Wei F. Dai
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
| | - Judith S. Jacobson
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
- Herbert Irving Comprehensive Cancer Center, College of Physicians and Surgeons, Columbia University, New York, New York
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19
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Ooi CY, Hanafi NS, Liew SM. Knowledge and practice of colorectal cancer screening in an urban setting: cross-sectional survey of primary care physicians in government clinics in Malaysia. Singapore Med J 2019; 60:596-604. [PMID: 30644527 DOI: 10.11622/smedj.2019011] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
INTRODUCTION Colorectal cancer (CRC) was the third most commonly diagnosed cancer worldwide in 2008 (1.23 million cases, 9.7%). CRC screening was shown to be effective in reducing 70% of CRC mortality. However, the screening rate for CRC remains poor. METHODS A cross-sectional survey was conducted among primary care physicians (PCPs) in public primary care clinics in Kuala Lumpur, Malaysia. A 30-item self-administered questionnaire was used to assess the knowledge and practice of CRC screening. RESULTS The response rate was 86.4% (n = 197/228). Less than half (39.1%) of the respondents answered correctly for all risk stratification scenarios. Mean knowledge score on CRC screening modalities was 48.7% ± 17.7%. The knowledge score was positively associated with having postgraduate educational qualification and usage of screening guidelines. Overall, 69.9% of PCPs reported that they practised screening. However, of these, only 25.9% of PCPs screened over 50% of all eligible patients. PCPs who agreed that screening was cost-effective (odds ratio [OR] 3.34, 95% confidence interval [CI] 1.69‒6.59) and those who agreed that they had adequate resources in their locality (OR 1.92, 95% CI 1.01‒3.68) were more likely to practise screening. Knowledge score was not associated with the practice of screening (p = 0.185). CONCLUSION Knowledge and practice of CRC screening was inadequate among PCPs. Knowledge of screening did not translate into its practice. PCPs' perceptions about cost-effectiveness of screening and adequate resources were important determinants of the practice of screening.
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Affiliation(s)
- Chor Yau Ooi
- Department of Family Medicine, Faculty of Medicine and Health Sciences, Universiti Malaysia Sarawak, Sarawak, Malaysia
| | - Nik Sherina Hanafi
- University of Malaya Primary Care Research Group, Department of Primary Care Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Su May Liew
- University of Malaya Primary Care Research Group, Department of Primary Care Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
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Kistler CE, Vu M, Sutkowi-Hemstreet A, Gizlice Z, Harris RP, Brewer NT, Lewis CL, Dolor RJ, Barclay C, Sheridan SL. Exploring factors that might influence primary-care provider discussion of and recommendation for prostate and colon cancer screening. Int J Gen Med 2018; 11:179-190. [PMID: 29844698 PMCID: PMC5962312 DOI: 10.2147/ijgm.s153887] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Background Primary-care providers may contribute to the use of low-value cancer screening. Objective We sought to examine circumstances under which primary-care providers would discuss and recommend two types of cancer screening services across a spectrum of net benefit and other factors known to influence screening. Patients and methods This was a cross sectional survey of 126 primary-care providers in 24 primary-care clinics in the US. Participants completed surveys with two hypothetical screening scenarios for prostate or colorectal cancer (CRC). Patients in the scenarios varied by age and screening-request status. For each scenario, providers indicated whether they would discuss and recommend screening. Providers also reported on their screening attitudes and the influence of other factors known to affect screening (short patient visits, worry about lawsuits, clinical reminders/performance measures, and screening guidelines). We examined associations between providers’ attitudes and their screening recommendations for hypothetical 90-year-olds (the lowest-value screening). Results Providers reported they would discuss cancer screening more often than they would recommend it (P<0.001). More providers would discuss and recommend screening for CRC than prostate cancer (P<0.001), for younger than older patients (P<0.001), and when the patient requested it than when not (P<0.001). For a 90-year-old patient, every point increase in cancer-specific screening attitude increased the likelihood of a screening recommendation (30% for prostate cancer and 30% for CRC). Discussion While most providers’ reported practice patterns aligned with net benefit, some providers would discuss and recommend low-value cancer screening, particularly when faced with a patient request. Conclusion More work appears to be needed to help providers to discuss and recommend screening that aligns with value.
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Affiliation(s)
| | - Maihan Vu
- Center for Health Promotion and Disease Prevention, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | | | - Ziya Gizlice
- Biostatistical Support Unit, Center for Health Promotion and Disease Prevention
| | | | - Noel T Brewer
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Carmen L Lewis
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO
| | - Rowena J Dolor
- Division of General Internal Medicine, Duke University School of Medicine, Durham, NC
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Syse A, Soneji SS, Andrew AS, Tretli S, Baili P, Bynum JPW. Short-term survival after colorectal cancer in a screened versus unscreened population. Scand J Public Health 2018; 47:528-537. [PMID: 29360010 DOI: 10.1177/1403494817744394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Aims: United States' (US) colorectal cancer (CRC) screening and treatment practices seek to reduce mortality. We examined the survival of US patients compared with patients in the virtually unscreened Norwegian population. Methods: We compared short-term survival after CRC between the US and Norway using relative survival (RS) and excess mortality (EMR) analyses. The CRC patients were aged 50 and older diagnosed in the US (Surveillance, Epidemiology and End Results registry, 2004, N=9511) and in Norway (Cancer Registry of Norway, 2003-2005, N=8256). Results: Death occurred within three years for 39% of the CRC patients. Stage distributions were more favorable for US patients. Stage-specific survival was similar for localized and regional cancers, but more favorable for US distant cancers. In multivariate models of patient, tumor and treatment characteristics, patients (especially below age 80) in the US experienced longer survival (EMR 0.9, CI 0.8-0.9). Stage-specific analyses showed, however, that survival for localized cancers was relatively shorter in the US than in Norway (EMR 1.4, CI 1.1-1.8), but longer for distant cancers (EMR 0.8, CI 0.7-0.8). Conclusions: The enhanced survival for US CRC patients likely reflects a screening-related earlier diagnostic stage distribution, as well as prioritized life extension for patients with metastatic cancers, reflecting vastly different health care systems in the two countries. CRC screening is currently under consideration in Norway. For survival outcomes, the current findings do not discourage such an implementation. Other screening-related aspects such as feasibility and cost-benefit are, however, also relevant and warrant further research within a socialized health system.
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Affiliation(s)
| | | | | | | | - Paolo Baili
- 4 Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Lombardia, Italy
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22
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Şahin MK, Aker S. Family Physicians' Knowledge, Attitudes, and Practices Toward Colorectal Cancer Screening. JOURNAL OF CANCER EDUCATION : THE OFFICIAL JOURNAL OF THE AMERICAN ASSOCIATION FOR CANCER EDUCATION 2017; 32:908-913. [PMID: 27193411 DOI: 10.1007/s13187-016-1047-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
The purpose of this study was to assess family physicians' knowledge, attitudes, and practices toward colorectal cancer (CRC) screening. The population in this cross-sectional study consisted of 290 family physicians working in Samsun, Turkey, contacted between 15 June and 15 July 2015 and agreeing to participate. A questionnaire prepared by the authors on the basis of the relevant literature was applied at face-to-face interviews. The first part of the questionnaire inquired into sociodemographic information, while the second contained questions evaluating family physicians' knowledge, attitudes, and practices toward CRC screening. Physicians completed the questionnaire in approximately 10 min. 65.9 % of the family physicians in the study were men. Mean age of the participants was 43.40 ± 6.54 years, and mean number of years in service was 18.43 ± 6.42. The average number of patients seen by physicians on a daily basis was 51-99. CRC screening was performed by 83.1 % of physicians. The fecal occult blood test (FOBT) was recommended at the correct frequency by 30.7 % of physicians and colonoscopy by 11.7 %. A further 68.6 % of physicians followed no CRC guideline. Only 3.8 % of those reporting using a guideline were able to name it. The great majority of physicians in this study apply CRC screening. However, family physicians lack sufficient information concerning the ages at which screening tests should be started and concluded and how frequently they should be performed. They also do not attach sufficient importance to CRC guidelines. This results in excessive demand for screening tests.
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Affiliation(s)
- Mustafa Kürşat Şahin
- Samsun Public Health Directorate, Canik Community Health Center, Gaziosmanpaşa Mah. Alaca Sok. No: 31, Canik, Samsun, Turkey.
| | - Servet Aker
- Samsun Public Health Directorate, Canik Community Health Center, Gaziosmanpaşa Mah. Alaca Sok. No: 31, Canik, Samsun, Turkey
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Abstract
Colorectal cancer (CRC) contributes a major burden of cancer mortality in the United States. There are multiple effective screening approaches that can reduce CRC mortality. These approaches are supported by different levels of evidence, and each has its own advantages and disadvantages. Implementing a systematic approach to screening that addresses the multiple steps involved in the screening process is essential to improving population-level CRC screening. Offering patients stool-based screening is important for increasing screening uptake. However, programs that offer stool testing must support the population health infrastructure needed to promote adherence to repeat testing and follow-up of abnormal tests.
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Affiliation(s)
- Alison T Brenner
- Cecil G Sheps Center for Health Services Research, University of North Carolina, 725 Martin Luther King Jr Boulevard, CB# 7590, Chapel Hill, NC 27599-7590, USA.
| | - Michael Dougherty
- Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina, 4182 Bioinformatics Building, 130 Mason Farm Road, Chapel Hill, NC 27599-6134, USA
| | - Daniel S Reuland
- Division of General Internal Medicine, Department of Medicine, University of North Carolina, 725 Martin Luther King Jr Boulevard, CB# 7590, Chapel Hill, NC 27599-7590, USA
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Keating NL, James O’Malley A, Onnela JP, Landon BE. Assessing the impact of colonoscopy complications on use of colonoscopy among primary care physicians and other connected physicians: an observational study of older Americans. BMJ Open 2017; 7:e014239. [PMID: 28645954 PMCID: PMC5623374 DOI: 10.1136/bmjopen-2016-014239] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVES Psychological biases can distort treatment decision-making. The availability heuristic is one such bias, wherein events that are recent, vivid or easily imagined are readily 'available' to memory and are therefore judged more likely to occur than expected based on epidemiological data. We assessed if the occurrence of a serious colonoscopy complication for a primary care physician's patient influenced colonoscopy rates for the physician's other patients. DESIGN Longitudinal study with time-varying exposure variables. SETTING/PARTICIPANTS Individuals living in 51 hospital referral regions across the USA identified based on enrolment in fee-for-service Medicare during 2005-2010. We assigned patients to a primary care physician based on office visits during the prior 2 years. EXPOSURES For each physician in each month, we calculated the proportion of patients assigned to them who had a colonoscopy. We identified two serious complications of which the primary care provider would very likely be aware: gastrointestinal bleed or perforation leading to hospitalisation or death within 14 days of colonoscopy. MAIN OUTCOME MEASURES We employed Poisson regression models including physician fixed effects to assess the change in number of colonoscopies in the four quarters following an adverse colonoscopy event. RESULTS We identified 5 360 191 patients assigned to 30 704 physicians. 4864 physicians (16%) had at least one patient with an adverse event. The estimated change in the quarterly number of colonoscopies among physicians' patients was significantly lower in quarter 2 following an adverse colonoscopy event (change=-2.1% (95% CI -3.4 to -0.8%)), before returning to the rate expected in the absence of an adverse event. CONCLUSIONS Having a patient experience a serious adverse colonoscopy event was associated with a small and temporary decline in colonoscopy rates among a physician's other patients. This finding provides empirical evidence for the influence of notable adverse events on care, possibly due to the availability heuristic.
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Affiliation(s)
- Nancy L Keating
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts, USA
- Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - A James O’Malley
- The Department of Biomedical Data Science, The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Hanover, Massachusetts, USA
| | - Jukka-Pekka Onnela
- Department of Biostatistics, Harvard T.H Chan School of Public Health, Boston, Massachusetts, USA
| | - Bruce E Landon
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts, USA
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
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Weingart SN, Stoffel EM, Chung DC, Sequist TD, Lederman RI, Pelletier SR, Shields HM. Working up rectal bleeding in adult primary care practices. J Eval Clin Pract 2017; 23:279-287. [PMID: 27436515 DOI: 10.1111/jep.12596] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2016] [Revised: 06/08/2016] [Accepted: 06/09/2016] [Indexed: 12/01/2022]
Abstract
RATIONALE, AIMS AND OBJECTIVES Variation in the workup of rectal bleeding may result in guideline-discordant care and delayed diagnosis of colorectal cancer. Accordingly, we undertook this study to characterize primary care clinicians' initial rectal bleeding evaluation. METHODS We studied 438 patients at 10 adult primary care practices affiliated with three Boston, Massachusetts, academic medical centres and a multispecialty group practice, performing medical record reviews of subjects with visit codes for rectal bleeding, haemorrhoids or bloody stool. Nurse reviewers abstracted patients' sociodemographic characteristics, rectal bleeding-related symptoms and components of the rectal bleeding workup. Bivariate and multivariable logistic regression models examined factors associated with guideline-discordant workups. RESULTS Clinicians documented a family history of colorectal cancer or polyps at the index visit in 27% of cases and failed to document an abdominal or rectal examination in 21% and 29%. Failure to order imaging or a diagnostic procedure occurred in 32% of cases and was the only component of the workup associated with guideline-discordant care, which occurred in 27% of cases. Compared with patients at hospital-based teaching sites, patients at urban clinics or community health centres had 2.9 (95% confidence interval 1.3-6.3) times the odds of having had an incomplete workup. Network affiliation was also associated with guideline concordance. CONCLUSION Workup of rectal bleeding was inconsistent, incomplete and discordant with guidelines in one-quarter of cases. Research and improvements strategies are needed to understand and manage practice and provider variation.
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Affiliation(s)
- Saul N Weingart
- Tufts Medical Center, Boston, MA, USA.,Tufts University School of Medicine, Boston, MA, USA
| | | | - Daniel C Chung
- Gastrointestinal Unit, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Thomas D Sequist
- Harvard Medical School, Boston, MA, USA.,Partners Healthcare System, Boston, MA, USA
| | - Ruth I Lederman
- Survey and Data Management Core, Dana-Farber Cancer Institute Boston, Boston, MA, USA
| | | | - Helen M Shields
- Harvard Medical School, Boston, MA, USA.,Division of Medical Communications, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
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Feng X, Tan X, Alenzi EO, Rai P, Chang J. Spatial and temporal variations of screening for breast and colorectal cancer in the United States, 2008 to 2012. Medicine (Baltimore) 2016; 95:e5656. [PMID: 28002335 PMCID: PMC5181819 DOI: 10.1097/md.0000000000005656] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Cancer screening tests are important tools to combat cancer-related morbidity and mortality. There is limited up-to-date research on spatial and temporal variations of colorectal and breast cancer screening in the United States.County-level data of cancer screening adherence rates were generated from 2008 to 2012 Behavioral Risk Factor Surveillance System. We performed the univariate local indicators for spatial analyses (LISA) for the geographic differences of screening adherence rate and the differential LISA for the change of screening adherence rate from 2008 to 2012.In the univariate LISA, low-to-low clusters were consistently identified in counties of New Mexico, Wyoming, and Mississippi (P < 0.05) for both screenings. In the differential LISA, we found low-to-low clusters in Indiana counties (P < 0.05) for mammography screening, which implied that counties with a below-average difference in mammography adherence were surrounded by counties of below-average difference in adherence rates. A high-to-high cluster was also identified in the southern Appalachian counties for mammography screening (P < 0.05). No obvious spatial pattern was found for the colorectal cancer screening adherence rate across the United States.We found low-to-low clusters over time in adherence to screening guidelines for both cancer types in New Mexico, Wyoming, and Mississippi, and clusters of potential decrease in adherence to mammography screening guideline in counties of Indiana. The study also showed improvement on mammography screening clustered in southern Appalachia. The methodology adopted in this study identified areas with clusters of consistent low adherence to screening and a decrease in adherence, which implies that further research and intervention is warranted.
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Affiliation(s)
- Xue Feng
- Department of Pharmaceutical Systems and Policy, West Virginia University, School of Pharmacy, Morgantown, WV
| | - Xi Tan
- Department of Pharmaceutical Systems and Policy, West Virginia University, School of Pharmacy, Morgantown, WV
| | - Ebtihag O. Alenzi
- Department of Pharmaceutical Systems and Policy, West Virginia University, School of Pharmacy, Morgantown, WV
| | - Pragya Rai
- Department of Pharmaceutical Systems and Policy, West Virginia University, School of Pharmacy, Morgantown, WV
| | - Jongwha Chang
- University of Texas at El Paso, School of Pharmacy, El Paso, TX
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Hoffman RM, Elmore JG, Pignone MP, Gerstein BS, Levin CA, Fairfield KM. Knowledge and values for cancer screening decisions: Results from a national survey. PATIENT EDUCATION AND COUNSELING 2016; 99:624-630. [PMID: 26603446 DOI: 10.1016/j.pec.2015.11.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Revised: 11/02/2015] [Accepted: 11/03/2015] [Indexed: 06/05/2023]
Abstract
BACKGROUND Guidelines recommend shared decision making (SDM) for cancer screening decisions. SDM requires providers to ensure that patients are informed about screening issues and to support decisions that are concordant with patient values. We evaluated decision-quality factors for breast, colorectal, and prostate cancer screening decisions. METHODS We conducted a national, population-based Internet survey of adults aged 40+ to characterize perceptions about about cancer screening, the importance of information sources, cancer screening knowledge, values and preferences for screening, and the most influential drivers of decisions. RESULTS Among 1452 participants who completed the survey, the mean age was 60, and 94% were insured. Most participants reported feeling well informed about cancer screening, though only 21% reported feeling extremely well informed. Most participants correctly answered about 50% of the knowledge questions, with the majority markedly overestimating lifetime risk of cancer diagnoses and mortality. Participants rated health care providers as the most important source of information. CONCLUSION Although respondents considered themselves well informed about cancer they performed poorly on knowledge questions. This discordance suggests the potential for poor-quality decision making. PRACTICE IMPLICATIONS To improve the quality of decision making, providers need training to utilize decision support tools and time to carry out SDM.
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Affiliation(s)
- Richard M Hoffman
- Department of Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, United States; Medicine Service, Iowa City VA Medical Center, Iowa City, IA, United States
| | - Joann G Elmore
- Department of Medicine, University of Washington School of Medicine, Seattle, WA, United States
| | - Michael P Pignone
- University of North Carolina Division of General Internal Medicine, Chapel Hill, NC, United States; University of North Carolina Institute for Healthcare Quality Improvement, Chapel Hill, NC, United States
| | - Bethany S Gerstein
- Informed Medical Decisions Foundation, Division of Healthwise, Inc. Boston, MA, United States
| | - Carrie A Levin
- Informed Medical Decisions Foundation, Division of Healthwise, Inc. Boston, MA, United States
| | - Kathleen M Fairfield
- Department of Medicine and Center for Outcomes Research and Evaluation, Maine Medical Center Research Institute, Portland, ME, United States.
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Abstract
The US Preventive Services Task Force recommends patient-physician discussions about the appropriateness of colorectal cancer (CRC) screening among adults ages 76-84 years who have never been screened. In this study, we used data from the 2010 National Health Interview Survey to examine patterns of CRC screening and provider recommendation among seniors ages 76-84 years, and made some comparisons to younger adults. Nationally-representative samples of 1379 adults ages 76-84 years and 8797 adults ages 50-75 years responded to questions about CRC screening status, receipt of provider recommendation, and discussion of test options; 22.7% (95% CI 20.1-25.3) of seniors ages 76-84 had never been tested for CRC and therefore were not up-to-date with guidelines; 3.9% (95% CI 2.0-7.6) of these individuals reported a recent provider recommendation for screening. In multivariate analyses, the likelihood of never having been tested was significantly greater for seniors of other/multiple race or Hispanic ethnicity; with high school or less education; without private health insurance coverage; who had ≤ 1 doctor visit in the past year; without recent screening for breast, cervical, or prostate cancer; with no or unknown CRC family history; or with ≤ 1 chronic disease. Among the minority of respondents ages 50-75 and 76-84 reporting a provider recommendation, 73.2% indicated that the provider recommended particular tests, which was overwhelmingly colonoscopy (≥ 89 %). Nearly one-quarter of adults 76-84 have never been screened for CRC, and rates of provider recommendation in this group are very low. Greater attention to informed CRC screening discussions with screening-eligible seniors is needed.
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Murphy CC, Sandler RS, Grubber JM, Johnson MR, Fisher DA. Underuse and Overuse of Colonoscopy for Repeat Screening and Surveillance in the Veterans Health Administration. Clin Gastroenterol Hepatol 2016; 14:436-444.e1. [PMID: 26492843 PMCID: PMC4761454 DOI: 10.1016/j.cgh.2015.10.008] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2015] [Revised: 10/05/2015] [Accepted: 10/06/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Regular screening with colonoscopy lowers colorectal cancer incidence and mortality. We aimed to determine patterns of repeat and surveillance colonoscopy and identify factors associated with overuse and underuse of colonoscopy. METHODS We analyzed data from participants in a previous Veterans Health Administration (VHA) study who underwent outpatient colonoscopy at 25 VHA facilities between October 2007 and September 2008 (n = 1455). The proportion of patients who received a follow-up colonoscopy was calculated for 3 risk groups, which were defined on the basis of the index colonoscopy: no adenoma, low-risk adenoma, or high-risk adenoma. RESULTS Colonoscopy was overused (used more frequently than intervals recommended by guidelines) by 16% of patients with no adenomas, 26% with low-risk adenomas, and 29% with high-risk adenomas. Most patients with high-risk adenomas (54%) underwent colonoscopy after the recommended interval or did not undergo colonoscopy. Patients who received a follow-up recommendation that was discordant with guidelines were more likely to undergo colonoscopy too early (no adenoma odds ratio [OR], 3.80; 95% confidence interval [CI], 2.31-6.25 and low-risk adenoma OR, 5.28; 95% CI, 1.88-14.83). Receipt of colonoscopy at nonacademic facilities was associated with overuse among patients without adenomas (OR, 5.26; 95% CI, 1.96-14.29) or with low-risk adenomas (OR, 3.45; 95% CI, 1.52-7.69). Performance of colonoscopies by general surgeons vs gastroenterologists (OR, 2.08; 95% CI, 1.02-4.23) and female sex of the patient (OR, 3.28; 95% CI, 1.06-10.16) were associated with overuse of colonoscopy for patients with low-risk adenomas. No factors examined were associated with underuse of colonoscopy among patients with high-risk adenomas. CONCLUSIONS In an analysis of patients in the VHA system, more than one fourth of patients with low-risk adenomas received follow-up colonoscopies too early, whereas more than one half of those with high-risk adenomas did not undergo surveillance colonoscopy as recommended. Our findings highlight the need for system-level improvements to facilitate the appropriate delivery of colonoscopy that is based on individual risk.
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Affiliation(s)
- Caitlin C. Murphy
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Robert S. Sandler
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, NC,Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill
| | - Janet M. Grubber
- Durham VA Health Services Research and Development Center, Durham, NC,Duke University Medical Center, Durham, NC
| | - Marcus R. Johnson
- Durham VA Health Services Research and Development Center, Durham, NC,VA Cooperative Studies Program Epidemiology Center, Durham, NC
| | - Deborah A. Fisher
- Durham VA Health Services Research and Development Center, Durham, NC,Duke University Medical Center, Durham, NC
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30
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Haas JS, Sprague BL, Klabunde CN, Tosteson ANA, Chen JS, Bitton A, Beaber EF, Onega T, Kim JJ, MacLean CD, Harris K, Yamartino P, Howe K, Pearson L, Feldman S, Brawarsky P, Schapira MM. Provider Attitudes and Screening Practices Following Changes in Breast and Cervical Cancer Screening Guidelines. J Gen Intern Med 2016; 31:52-9. [PMID: 26129780 PMCID: PMC4700005 DOI: 10.1007/s11606-015-3449-5] [Citation(s) in RCA: 74] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Changes to national guidelines for breast and cervical cancer screening have created confusion and controversy for women and their primary care providers. OBJECTIVE To characterize women's primary health care provider attitudes towards screening and changes in practice in response to recent revisions in guidelines for breast and cervical cancer screening. DESIGN, SETTING, PARTICIPANTS In 2014, we distributed a confidential web and mail survey to 668 women's health care providers affiliated with the four clinical care networks participating in the three PROSPR (Population-based Research Optimizing Screening through Personalized Regimens) consortium breast cancer research centers (385 respondents; response rate 57.6 %). MAIN MEASURES We assessed self-reported attitudes toward breast and cervical cancer screening, as well as practice changes in response to the most recent revisions of the U.S. Preventive Services Task Force (USPSTF) recommendations. KEY RESULTS The majority of providers believed that mammography screening was effective for reducing cancer mortality among women ages 40-74 years, and that Papanicolaou (Pap) testing was very effective for women ages 21-64 years. While the USPSTF breast and cervical cancer screening recommendations were widely perceived by the respondents as influential, 75.7 and 41.2 % of providers (for mammography and cervical cancer screening, respectively) reported screening practices in excess of those recommended by USPSTF. Provider-reported barriers to concordance with guideline recommendations included: patient concerns (74 and 36 % for breast and cervical, respectively), provider disagreement with the recommendations (50 and 14 %), health system measurement of a provider's screening practices that use conflicting measurement criteria (40 and 21 %), concern about malpractice risk (33 and 11 %), and lack of time to discuss the benefits and harms with their patients (17 and 8 %). CONCLUSIONS Primary care providers do not consistently follow recent USPSTF breast and cervical cancer screening recommendations, despite noting that these guidelines are influential.
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Affiliation(s)
- Jennifer S Haas
- Brigham and Women's Hospital, Boston, MA, USA.
- Harvard Medical School, Boston, MA, USA.
- Harvard T.H. Chan School of Public Health, Boston, MA, USA.
- Division of General Medicine and Primary Care, Brigham and Women's Hospital, 1620 Tremont Street, Boston, MA, 02120, USA.
| | | | - Carrie N Klabunde
- Office of Disease Prevention, Office of the Director, National Institutes of Health, Bethesda, MD, USA
| | - Anna N A Tosteson
- Geisel School of Medicine at Dartmouth and Norris Cotton Cancer Center, Lebanon, NH, USA
| | - Jane S Chen
- Brigham and Women's Hospital, Boston, MA, USA
| | - Asaf Bitton
- Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | | | - Tracy Onega
- Geisel School of Medicine at Dartmouth and Norris Cotton Cancer Center, Lebanon, NH, USA
| | - Jane J Kim
- Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | | | | | - Phillip Yamartino
- University of Pennsylvania and the Philadelphia VA Medical Center, Philadelphia, PA, USA
| | | | - Loretta Pearson
- Geisel School of Medicine at Dartmouth and Norris Cotton Cancer Center, Lebanon, NH, USA
| | - Sarah Feldman
- Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | | | - Marilyn M Schapira
- University of Pennsylvania and the Philadelphia VA Medical Center, Philadelphia, PA, USA
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Johnson MR, Grubber J, Grambow SC, Maciejewski ML, Dunn-Thomas T, Provenzale D, Fisher DA. Physician Non-adherence to Colonoscopy Interval Guidelines in the Veterans Affairs Healthcare System. Gastroenterology 2015; 149:938-51. [PMID: 26122143 DOI: 10.1053/j.gastro.2015.06.026] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2014] [Revised: 06/17/2015] [Accepted: 06/19/2015] [Indexed: 01/24/2023]
Abstract
BACKGROUND & AIMS Colonoscopy can decrease colorectal cancer (CRC) mortality, although performing this procedure more frequently than recommended could increase costs and risks to patients. We aimed to determine rates and correlates of physician non-adherence to guidelines for repeat colonoscopy screening and polyp surveillance intervals. METHODS We performed a multi-center, retrospective, observational study using administrative claims, physician databases, and electronic medical records (EMR) from 1455 patients (50-64 y old) who underwent colonoscopy in the Veterans Affairs healthcare system in fiscal year 2008. Patients had no prior diagnosis of CRC or inflammatory bowel disease, and had not undergone colonoscopy examinations in the previous 10 years. We compared EMR-documented, endoscopist-recommended intervals for colonoscopies with intervals recommended by the 2008 Multi-Society Task Force guidelines. RESULTS The overall rate of non-adherence to guideline recommendations was 36% and ranged from 3% to 80% among facilities. Non-adherence was 28% for patients who underwent normal colonoscopies, but 45%-52% after colonoscopies that identified hyperplastic or adenomatous polyps. Most of all recommendations that were not followed recommended a shorter surveillance interval. In adjusted analyses, non-adherence was significantly higher for patients whose colonoscopies identified hyperplastic (odds ratio [OR] = 3.1; 95% CI, 1.7-5.5) or high-risk adenomatous polyps (OR = 3.0; 95% CI, 1.2-8.0), compared to patients with normal colonoscopy examinations, but not for patients with low-risk adenomatous polyps (OR = 1.8; 95% CI, 0.9-3.7). Nonadherence was also associated with bowel preparation quality, geographic region, Charlson comorbidity score, and colonoscopy indication. CONCLUSIONS In a managed care setting with salaried physicians, endoscopists recommend repeat colonoscopy sooner than guidelines for more than one third of patients. Factors associated with non-adherence to guideline recommendations were colonoscopy findings, quality of bowel preparation, and geographic region. Targeting endoscopist about non-adherence to colonoscopy guidelines could reduce overuse of colonoscopy and associated healthcare costs.
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Affiliation(s)
- Marcus R Johnson
- Cooperative Studies Program Epidemiology Center-Durham, Durham Veterans Affairs Medical Center, Durham, North Carolina; Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, North Carolina
| | - Janet Grubber
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, North Carolina
| | - Steven C Grambow
- Cooperative Studies Program Epidemiology Center-Durham, Durham Veterans Affairs Medical Center, Durham, North Carolina; Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina
| | - Matthew L Maciejewski
- Cooperative Studies Program Epidemiology Center-Durham, Durham Veterans Affairs Medical Center, Durham, North Carolina; Division of General Internal Medicine, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Tyra Dunn-Thomas
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, North Carolina
| | - Dawn Provenzale
- Cooperative Studies Program Epidemiology Center-Durham, Durham Veterans Affairs Medical Center, Durham, North Carolina; Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, North Carolina; Division of Gastroenterology, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Deborah A Fisher
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, North Carolina; Division of Gastroenterology, Department of Medicine, Duke University Medical Center, Durham, North Carolina.
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Predictors of guideline concordance for surveillance colonoscopy recommendations in patients at a safety-net health system. Cancer Causes Control 2015; 26:1653-60. [PMID: 26376891 DOI: 10.1007/s10552-015-0661-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Accepted: 09/03/2015] [Indexed: 12/24/2022]
Abstract
PURPOSE Appropriate surveillance intervals for colorectal cancer (CRC) screening is one of the Centers for Medicare and Medicaid Services 2014 physician quality reporting system measures. Appropriateness of surveillance intervals will continue to be monitored closely, particularly as reimbursements become tied to quality measures. AIMS Quantify and identify predictors for guideline-concordant surveillance recommendations after adenoma polypectomy. METHODS We conducted a retrospective cohort study of patients who had colonoscopy with polypectomy at a safety-net health system between June 2011 and December 2013. Surveillance recommendations shorter and longer than guideline recommendations were defined as potential overuse and underuse. We used multivariate logistic regression to identify correlates of guideline-concordant surveillance recommendations, overuse, and underuse. RESULTS Among 1,822 patients with polypectomy, 1,329 had ≥1 adenoma. Surveillance interval recommendations were guideline-concordant in 1,410 (77.4%) patients, potential overuse in 263 (14.4%), potential underuse in 85 (4.7%), and missing in 64 (3.5%) patients. Predictors of guideline-concordant recommendations in multivariate analyses included age >65 years (OR 1.36, 95% CI 1.02-1.80), incomplete resection (OR 3.58, 95% CI 1.41-9.09), and good/excellent prep quality (OR 2.22, 95% CI 1.72-2.86). Underuse recommendations were more likely in patients with ≥3 adenomas; overuse recommendations were more likely in patients with high-grade dysplasia or fair prep quality and less likely in those with piecemeal resection, ≥3 adenomas, age >65, or Hispanic ethnicity. CONCLUSIONS Surveillance recommendations are not concordant with guidelines in one of four cases. Interventions to improve prep quality and guideline concordance of surveillance recommendations can improve cost-effectiveness of CRC screening.
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Fedewa SA, Ma J, Sauer AG, Siegel RL, Smith RA, Wender RC, Doroshenk MK, Brawley OW, Ward EM, Jemal A. How many individuals will need to be screened to increase colorectal cancer screening prevalence to 80% by 2018? Cancer 2015; 121:4258-65. [PMID: 26308967 DOI: 10.1002/cncr.29659] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2015] [Revised: 07/20/2015] [Accepted: 07/21/2015] [Indexed: 11/09/2022]
Abstract
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.
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Affiliation(s)
- Stacey A Fedewa
- Surveillance and Health Services Research, American Cancer Society, Atlanta, Georgia.,Department of Epidemiology, Emory University, Atlanta, Georgia
| | - Jiemin Ma
- Surveillance and Health Services Research, American Cancer Society, Atlanta, Georgia
| | - Ann Goding Sauer
- Surveillance and Health Services Research, American Cancer Society, Atlanta, Georgia
| | - Rebecca L Siegel
- Surveillance and Health Services Research, American Cancer Society, Atlanta, Georgia
| | - Robert A Smith
- Cancer Control Science, American Cancer Society, Atlanta, Georgia
| | - Richard C Wender
- Cancer Control Science, American Cancer Society, Atlanta, Georgia
| | - Mary K Doroshenk
- Cancer Control Science, American Cancer Society, Atlanta, Georgia
| | - Otis W Brawley
- Office of the Chief Medical Officer, American Cancer Society, Atlanta, Georgia
| | - Elizabeth M Ward
- Surveillance and Health Services Research, American Cancer Society, Atlanta, Georgia
| | - Ahmedin Jemal
- Surveillance and Health Services Research, American Cancer Society, Atlanta, Georgia
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Iskandar H, Yan Y, Elwing J, Early D, Colditz GA, Wang JS. Predictors of Poor Adherence of US Gastroenterologists with Colonoscopy Screening and Surveillance Guidelines. Dig Dis Sci 2015; 60:971-8. [PMID: 25366146 PMCID: PMC4409458 DOI: 10.1007/s10620-014-3403-0] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2014] [Accepted: 10/13/2014] [Indexed: 12/20/2022]
Abstract
BACKGROUND The US Multi-Society Task Force on Colorectal Cancer published guidelines for colonoscopy screening and surveillance in 2008 and affirmed them in 2012. Characteristics associated with guideline adherence among US gastroenterologists have not been assessed. AIM Assess awareness and adherence of US gastroenterologists with national guidelines for colonoscopy screening and surveillance and predictors of adherence to guidelines. METHODS A Web-based survey was administered to gastroenterologists in various practice settings across the USA. RESULTS A total of 306 gastroenterologists completed the survey; 86 % reported awareness of the guidelines. Low-volume colonoscopists (<20/month) were less likely to be aware of the guidelines (OR 0.26, p = 0.03) compared to high-volume colonoscopists (>100/month). Those completing training before 1990 were less likely to report following guidelines (OR 0.37, p = 0.01). Adherence with guidelines was then assessed via clinical scenarios. Compared to physicians finishing training in 1991-2010, less adherence was seen in those finishing before 1990 (OR 0.75, p < 0.001) or currently in training (OR 0.72, p = 0.004). Compared to the Western USA, less adherence was seen in the Midwest (OR 0.69, p = 0.001), Northeast (OR 0.63, p < 0.001), and South (OR 0.59, p < 0.001). Lower adherence was seen among non-academic physicians (OR 0.72, p = 0.001) and low-volume colonoscopists (OR 0.52, p < 0.001). CONCLUSIONS There is poor adherence with colonoscopy screening and surveillance guidelines among US gastroenterologists. Poor adherence was associated with being in training or finishing training before 1990, practicing in the South, non-academic settings, and low colonoscopy volume. These findings can target interventions for quality improvement in colorectal cancer screening and surveillance.
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Affiliation(s)
- Heba Iskandar
- Division of Gastroenterology, Washington University in St. Louis School of Medicine St. Louis, Missouri, USA
| | - Yan Yan
- Division of Public Health Sciences, Washington University in St. Louis School of Medicine St. Louis, Missouri, USA
| | - Jill Elwing
- Division of Gastroenterology, Washington University in St. Louis School of Medicine St. Louis, Missouri, USA
| | - Dayna Early
- Division of Gastroenterology, Washington University in St. Louis School of Medicine St. Louis, Missouri, USA
| | - Graham A. Colditz
- Division of Public Health Sciences, Washington University in St. Louis School of Medicine St. Louis, Missouri, USA
| | - Jean S. Wang
- Division of Gastroenterology, Washington University in St. Louis School of Medicine St. Louis, Missouri, USA
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Dalton-Fitzgerald E, Tiro J, Kandunoori P, Halm EA, Yopp A, Singal AG. Practice patterns and attitudes of primary care providers and barriers to surveillance of hepatocellular carcinoma in patients with cirrhosis. Clin Gastroenterol Hepatol 2015; 13:791-8.e1. [PMID: 25019694 PMCID: PMC4289665 DOI: 10.1016/j.cgh.2014.06.031] [Citation(s) in RCA: 78] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2014] [Revised: 06/26/2014] [Accepted: 06/27/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Fewer than 20% of patients with cirrhosis undergo surveillance for hepatocellular carcinoma (HCC), therefore these tumors often are detected at late stages. Although primary care providers (PCPs) care for 60% of patients with cirrhosis in the United States, little is known about their practice patterns for HCC surveillance. We investigated factors associated with adherence to guidelines for HCC surveillance by PCPs. METHODS We conducted a web-based survey of all 131 PCPs at a large urban hospital. The survey was derived from validated surveys and pretested among providers; it included questions about provider and practice characteristics, self-reported rates of surveillance, surveillance test and frequency preference, and attitudes and barriers to HCC surveillance. RESULTS We obtained a clinic-level response rate of 100% and a provider-level response rate of 60%. Only 65% of respondents reported annual surveillance and 15% reported biannual surveillance of patients for HCC. Barriers to HCC surveillance included not being up-to-date with HCC guidelines (68% of PCPs), difficulties in communicating effectively with patients about HCC surveillance (56%), and more important issues to manage in the clinic (52%). Approximately half of PCPs (52%) reported using ultrasound or measurements of α-fetoprotein in surveillance; 96% said that this combination was effective in reducing HCC-related mortality. However, many providers incorrectly believed that clinical examination (45%) or levels of liver enzymes (59%) or α-fetoprotein alone (89%) were effective surveillance tools. CONCLUSIONS PCPs have misconceptions about tests to detect HCC that contribute to ineffective surveillance. Reported barriers to surveillance include suboptimal knowledge about guidelines, indicating a need for interventions, including provider education, to increase HCC surveillance effectiveness.
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Affiliation(s)
- Eimile Dalton-Fitzgerald
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas; Department of Internal Medicine, Parkland Health Hospital System, Dallas, Texas
| | - Jasmin Tiro
- Harold C. Simmons Cancer Center, University of Texas Southwestern Medical Center, Dallas, Texas; Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Pragathi Kandunoori
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas; Department of Internal Medicine, Parkland Health Hospital System, Dallas, Texas
| | - Ethan A Halm
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas; Department of Internal Medicine, Parkland Health Hospital System, Dallas, Texas; Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Adam Yopp
- Harold C. Simmons Cancer Center, University of Texas Southwestern Medical Center, Dallas, Texas; Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Amit G Singal
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas; Department of Internal Medicine, Parkland Health Hospital System, Dallas, Texas; Harold C. Simmons Cancer Center, University of Texas Southwestern Medical Center, Dallas, Texas; Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, Texas.
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Kruse GR, Khan SM, Zaslavsky AM, Ayanian JZ, Sequist TD. Overuse of colonoscopy for colorectal cancer screening and surveillance. J Gen Intern Med 2015; 30:277-83. [PMID: 25266407 PMCID: PMC4351286 DOI: 10.1007/s11606-014-3015-6] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2014] [Revised: 05/08/2014] [Accepted: 08/14/2014] [Indexed: 01/09/2023]
Abstract
BACKGROUND Ongoing efforts to increase colorectal cancer (CRC) screening rates have raised concerns that these exams may be overused, thereby subjecting patients to unnecessary risks and wasting healthcare resources. OBJECTIVE Our aim was to measure overuse of screening and surveillance colonoscopies among average-risk adults, and to identify correlates of overuse. DESIGN, SETTING, AND PARTICIPANTS Our approach was a retrospective cohort study using electronic health record data for patients 50-65 years old with no personal history of CRC or colorectal adenomas with an incident CRC screening colonoscopy from 2001 to 2010 within a multispecialty physician group practice. MAIN OUTCOME MEASURES We measured time to next screening or surveillance colonoscopy and predictors of overuse (exam performed more than one year earlier than guideline recommended intervals) of colonoscopies. KEY RESULTS We identified 1,429 adults who had an incident colonoscopy between 2001 and 2010, and they underwent an additional 871 screening or surveillance colonoscopies during a median follow-up of 6 years. Most follow-up screening colonoscopies (88%) and many surveillance colonoscopies (49%) repeated during the study represented overuse. Time to next colonoscopy after incident screening varied by exam findings (no polyp: median 6.9 years, interquartile range [IQR]: 5.1-10.0; hyperplastic polyp: 5.7 years, IQR: 4.9-9.7; low-risk adenoma: 5.1 years, IQR: 3.3-6.3; high-risk adenoma: 2.9 years, IQR: 2.0-3.4, p < 0.001). In logistic regression models of colonoscopy overuse, an endoscopist recommendation for early follow-up was strongly associated with overuse of screening colonoscopy (OR 6.27, 95% CI: 3.15-12.50) and surveillance colonoscopy (OR 13.47, 95% CI 6.61-27.46). In a multilevel logistic regression model, variation in the overuse of screening colonoscopy was significantly associated with the endoscopist performing the previous exam. CONCLUSIONS Overuse of screening and surveillance exams are common and should be monitored by healthcare systems. Variations in endoscopist recommendations represent targets for interventions to reduce overuse.
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Affiliation(s)
- Gina R Kruse
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA,
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Nassery N, Segal JB, Chang E, Bridges JFP. Systematic overuse of healthcare services: a conceptual model. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2015; 13:1-6. [PMID: 25193241 PMCID: PMC5511697 DOI: 10.1007/s40258-014-0126-5] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
A perfect storm of factors influences the overuse of healthcare services in the USA. Considerable attention has been placed on geographic variation in utilization; however, empiric data has shown that geographic variation in utilization is not associated with overuse. While there has been renewed interest in overuse in recent years, much of the focus has been on the overuse of individual procedures. In this paper we argue that overuse should be thought of as a widespread and pervasive phenomenon that we coin as systematic overuse. While not directly observable (i.e., a latent phenomenon), we suggest that systematic overuse could be identified by tracking a portfolio of overused procedures. Such a portfolio would reflect systematic overuse if it is associated with higher healthcare costs and no health benefit (including worse health outcomes) across a healthcare system. In this report we define and conceptualize systematic overuse and illustrate how it can be identified and validated via a simple empirical example using several Choosing Wisely indicators. The concept of systematic overuse requires further development and empirical verification, and this paper provides an important first step, a conceptual framework, to that end.
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Affiliation(s)
- Najlla Nassery
- Division of General Internal Medicine, Johns Hopkins University School of Medicine, 5200 Eastern Ave, MFL Building Center Tower, Suite 2300, Baltimore, MD, 21224, USA,
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Partin MR, Burgess DJ, Burgess JF, Gravely A, Haggstrom D, Lillie SE, Nugent S, Powell AA, Shaukat A, Walter LC, Nelson DB. Organizational predictors of colonoscopy follow-up for positive fecal occult blood test results: an observational study. Cancer Epidemiol Biomarkers Prev 2015; 24:422-34. [PMID: 25471345 PMCID: PMC4323731 DOI: 10.1158/1055-9965.epi-14-1170] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND This study assessed the contribution of organizational structures and processes identified from facility surveys to follow-up for positive fecal occult blood tests [FOBT-positive (FOBT(+))]. METHODS We identified 74,104 patients with FOBT(+) results from 98 Veterans Health Administration (VHA) facilities between August 16, 2009 and March 20, 2011, and followed them until September 30, 2011, for completion of colonoscopy. We identified patient characteristics from VHA administrative records, and organizational factors from facility surveys completed by primary care and gastroenterology chiefs. We estimated predictors of colonoscopy completion within 60 days and six months using hierarchical logistic regression models. RESULTS Thirty percent of patients with FOBT(+) results received colonoscopy within 60 days and 49% within six months. Having gastroenterology or laboratory staff notify gastroenterology providers directly about FOBT(+) cases was a significant predictor of 60-day [odds ratio (OR), 1.85; P = 0.01] and six-month follow-up (OR, 1.25; P = 0.008). Additional predictors of 60-day follow-up included adequacy of colonoscopy appointment availability (OR, 1.43; P = 0.01) and frequent individual feedback to primary care providers about FOBT(+) referral timeliness (OR, 1.79; P = 0.04). Additional predictors of six-month follow-up included using guideline-concordant surveillance intervals for low-risk adenomas (OR, 1.57; P = 0.01) and using group appointments and combined verbal-written methods for colonoscopy preparation instruction (OR, 1.48; P = 0.0001). CONCLUSION Directly notifying gastroenterology providers about FOBT(+) results, using guideline-concordant adenoma surveillance intervals, and using colonoscopy preparations instruction methods that provide both verbal and written information may increase overall follow-up rates. Enhancing follow-up within 60 days may require increased colonoscopy capacity and feedback to primary care providers. IMPACT These findings may inform organizational-level interventions to improve FOBT(+) follow-up.
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Affiliation(s)
- Melissa R Partin
- Center for Chronic Disease Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota. Department of Medicine, University of Minnesota, Minneapolis, Minnesota.
| | - Diana J Burgess
- Center for Chronic Disease Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota. Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - James F Burgess
- Center for Healthcare Organization and Implementation Research, Boston Veterans Affairs Health Care System, Boston, Massachusetts. Department of Health Policy and Management, Boston University School of Public Health, Boston, Massachusetts
| | - Amy Gravely
- Center for Chronic Disease Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota
| | - David Haggstrom
- VA Health Services Research and Development Center for Health Information and Communication, Roudebush VAMC, Indianapolis, Indiana. Division of General Internal Medicine and Geriatrics, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Sarah E Lillie
- Center for Chronic Disease Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota. Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Sean Nugent
- Center for Chronic Disease Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota
| | - Adam A Powell
- Center for Chronic Disease Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota
| | - Aasma Shaukat
- Center for Chronic Disease Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota. Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Louise C Walter
- Division of Geriatrics, San Francisco VA Medical Center and University of California, San Francisco, San Francisco, California
| | - David B Nelson
- Center for Chronic Disease Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota. Department of Medicine, University of Minnesota, Minneapolis, Minnesota
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Garcia M. Addressing overuse and overdiagnosis in colorectal cancer screening for average-risk individuals. COLORECTAL CANCER 2015. [DOI: 10.2217/crc.15.4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
SUMMARY Inappropriate screening harms healthy individuals and squanders precious resources. The purpose of this review is to address harms of colorectal cancer screening derived from overuse and overdiagnosis in average-risk individuals. Overuse is associated with shorter than recommended repeat screening and surveillance intervals, and screening in individuals who would not derive benefit because of advanced age or significant comorbidity. Overuse can unnecessarily increase patient harm from overdiagnosis or colonoscopy complications as well as gastroenterologist workload and healthcare costs. There is no evidence to suggest that overdiagnosis is an issue for colorectal cancer screening. However, targeting on cancer prevention (detection of adenomatous polyps) rather than early detection will lead to overdiagnosis as only a small minority of polyps develop into cancer.
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Islami Parkoohi P, Zare H, Abdollahifard G. An experience of qualified preventive screening: shiraz smart screening software. IRANIAN JOURNAL OF MEDICAL SCIENCES 2015; 40:51-7. [PMID: 25648047 PMCID: PMC4300481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/07/2013] [Revised: 07/01/2013] [Accepted: 08/24/2013] [Indexed: 11/20/2022]
Abstract
BACKGROUND Computerized preventive screening software is a cost effective intervention tool to address non-communicable chronic diseases. Shiraz Smart Screening Software (SSSS) was developed as an innovative tool for qualified screening. It allows simultaneous smart screening of several high-burden chronic diseases and supports reminder notification functionality. The extent in which SSSS affects screening quality is also described. METHODS Following software development, preventive screening and annual health examinations of 261 school staff (Medical School of Shiraz, Iran) was carried out in a software-assisted manner. To evaluate the quality of the software-assisted screening, we used quasi-experimental study design and determined coverage, irregular attendance and inappropriateness proportions in relation with the manual and software-assisted screening as well as the corresponding number of requested tests. RESULTS In manual screening method, 27% of employees were covered (with 94% irregular attendance) while by software-assisted screening, the coverage proportion was 79% (attendance status will clear after the specified time). The frequency of inappropriate screening test requests, before the software implementation, was 41.37% for fasting plasma glucose, 41.37% for lipid profile, 0.84% for occult blood, 0.19% for flexible sigmoidoscopy/colonoscopy, 35.29% for Pap smear, 19.20% for mammography and 11.2% for prostate specific antigen. All of the above were corrected by the software application. In total, 366 manual screening and 334 software-assisted screening tests were requested. CONCLUSION SSSS is an innovative tool to improve the quality of preventive screening plans in terms of increased screening coverage, reduction in inappropriateness and the total number of requested tests.
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Singal AG, Gupta S, Lee J, Halm EA, Rutter CM, Corley D, Inadomi J. Importance of determining indication for colonoscopy: implications for practice and policy original. Clin Gastroenterol Hepatol 2014; 12:1958-63.e1-3. [PMID: 25606584 PMCID: PMC4303343 DOI: 10.1016/j.cgh.2014.09.028] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Amit G Singal
- Department of Internal Medicine and Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, Texas 75390-8887, USA.
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Miller JW, Baldwin LM, Matthews B, Trivers KF, Andrilla CH, Lishner D, Goff BA. Physicians' beliefs about effectiveness of cancer screening tests: a national survey of family physicians, general internists, and obstetrician-gynecologists. Prev Med 2014; 69:37-42. [PMID: 25038531 PMCID: PMC4539137 DOI: 10.1016/j.ypmed.2014.07.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2014] [Revised: 06/04/2014] [Accepted: 07/09/2014] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To study physicians' beliefs about the effectiveness of different tests for cancer screening. METHODS Data were examined from the Women's Health Survey of 1574 Family Medicine, Internal Medicine, and Obstetrics-Gynecology physicians to questions about their level of agreement about the clinical effectiveness of different tests for breast, cervical, ovarian, and colorectal cancer screening among average risk women. Data were weighted to the U.S. physician population based on the American Medical Association Masterfile. Multivariable logistic regression identified physician and practice characteristics significantly associated with physicians' beliefs. RESULTS There were 1574 respondents, representing a 62% response rate. The majority of physicians agreed with the effectiveness of mammography for women aged 50-69years, Pap tests for women aged 21-65years, and colonoscopy for individuals aged ≥50years. A substantial proportion of physicians believed that non-recommended tests were effective for screening (e.g., 34.4% for breast MRI and 69.1% for annual pelvic exam). Physicians typically listed their respective specialty organizations as a top influential organization for screening recommendations. CONCLUSIONS There were several substantial inconsistencies between physician beliefs in the effectiveness of cancer screening tests and the actual evidence of these tests' effectiveness which can lead both to underuse and overuse of cancer screening tests.
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Affiliation(s)
- Jacqueline W Miller
- Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA, USA.
| | - Laura-Mae Baldwin
- Department of Family Medicine, University of Washington, Seattle, WA, USA
| | - Barbara Matthews
- Department of Family Medicine, University of Washington, Seattle, WA, USA
| | - Katrina F Trivers
- Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - C Holly Andrilla
- Department of Family Medicine, University of Washington, Seattle, WA, USA
| | - Denise Lishner
- Department of Family Medicine, University of Washington, Seattle, WA, USA
| | - Barbara A Goff
- Department of Obstetrics and Gynecology, University of Washington, Seattle, WA, USA
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Postcolonoscopy Followup Recommendations: Comparison with and without Use of Polyp Pathology. DIAGNOSTIC AND THERAPEUTIC ENDOSCOPY 2014; 2014:683491. [PMID: 25242879 PMCID: PMC4163416 DOI: 10.1155/2014/683491] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/17/2014] [Accepted: 08/19/2014] [Indexed: 12/16/2022]
Abstract
Background. Appropriate recommendations for a followup exam after an index colonoscopy are an important quality indicator. Lack of knowledge of polyp pathology at the time of colonoscopy may be one reason that followup recommendations are not made. Aim. To describe and compare the accuracy of followup recommendations made at colonoscopy based on the size and number of polyps with recommendations made at a later date based on actual polyp pathology. Methods. All patients who underwent screening and surveillance colonoscopy from March, 2012, to August, 2012, were included. Surveillance recommendations from the endoscopy reports were graded as “accurate” or “not accurate” based on the postpolypectomy surveillance guidelines established by US Multisociety Task Force on Colon Cancer. Polyp pathology was then used to regrade the surveillance recommendations. Results. Followup recommendations were accurate in 759/884 (86%) of the study colonoscopies, based upon size and number of polyps with the assumption that all polyps were adenomatous. After incorporating actual polyp pathology, 717/884 (81%) colonoscopies had accurate recommendations. Conclusion. In our practice, the knowledge of actual polyp pathology does not change the surveillance recommendations made at the time of colonoscopy in the majority of patients.
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van Dam L, Bretthauer M. Ethical issues in colorectal cancer screening. Best Pract Res Clin Gastroenterol 2014; 28:315-26. [PMID: 24810192 DOI: 10.1016/j.bpg.2014.03.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2014] [Accepted: 03/02/2014] [Indexed: 02/07/2023]
Abstract
In many countries, colorectal cancer screening is currently an established population screening program due to the evidence on its reduction of colorectal cancer mortality. There is general consensus that colorectal cancer screening meets the screening criteria as proposed by Wilson and Jungner. However, as for all population screening programs, colorectal cancer screening also has disadvantages and thereby entails ethical issues. There are the general issues concerning the introduction of screening programs (e.g. medicalization, overdiagnosis and overtreatment, information provision to screenees), evaluation of cancer screening programs (e.g. lead time and length bias), chosen screening method (e.g. false-positive and false-negative test results, reduction of all-cause mortality, choice between different screening methods). The different colorectal cancer screening methods and the ethical issues concerning colorectal cancer screening will be discussed in this review.
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Affiliation(s)
- Leonie van Dam
- Department of Gastroenterology and Hepatology, University Medical Centre Rotterdam, The Netherlands; Department of Medical Ethics and Philosophy, University Medical Centre Rotterdam, The Netherlands.
| | - Michael Bretthauer
- Institute of Health and Society, University of Oslo, Oslo, Norway; Department of Transplantation Medicine, Section of Gastroenterology, Oslo University Hospital, Oslo, Norway.
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Chan V, Blazey W, Tegay D, Harper B, Koehler S, Laurent B, Lipka S, Cohn J, Jung MK, Krishnamachari B. Impact of academic affiliation and training on knowledge of hereditary colorectal cancer. Public Health Genomics 2014; 17:76-83. [PMID: 24458016 DOI: 10.1159/000356938] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2013] [Accepted: 10/31/2013] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Knowledge about hereditary colorectal cancer (CRC) can aid cancer screening and prevention in high-risk patients. Genetic testing, once conducted primarily at academic centers, is now routinely performed in a variety of clinics. Nonacademic physicians may not be aware of hereditary CRC standards of care. METHODS From August to November 2012, a survey was administered to predominantly primary care physicians evaluating academic center affiliation, past training in genetics and knowledge regarding hereditary CRC. RESULTS One hundred forty physicians completed the survey. Knowledge of hereditary CRC was neither associated with academic affiliation nor with training during medical school or residency, but with continuing medical education (CME) training. Those with CME training were more likely to know that screening could be enhanced for patients with a hereditary cancer risk (OR = 4.49, 95% CI = 1.40-14.38) and that an individual with hereditary CRC would have different screening recommendations (OR = 7.49, 95% CI = 1.37-40.81). Residency training and CME training were associated with more frequent hereditary risk assessment. CONCLUSION Genetics training may be associated with physicians' knowledge and assessment of hereditary CRC. Training at the CME level in particular may be integral to the delivery of genetic services in clinical practice.
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Affiliation(s)
- V Chan
- Department of Medicine, NYIT College of Osteopathic Medicine, Old Westbury, N.Y., USA
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Klabunde CN, Clauser SB, Liu B, Pronk NP, Ballard-Barbash R, Huang TTK, Smith AW. Organization of Primary Care Practice for Providing Energy Balance Care. Am J Health Promot 2014; 28:e67-80. [DOI: 10.4278/ajhp.121219-quan-626] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose. Primary care physicians (PCPs) may not adequately counsel or monitor patients regarding diet, physical activity, and weight control (i.e., provide energy balance care). We assessed the organization of PCPs' practices for providing this care. Design. The study design was a nationally representative survey conducted in 2008. Setting. The study setting was U.S. primary care practices. Subjects. A total of 1740 PCPs completed two sequential questionnaires (response rate, 55.5%). Measures. The study measured PCPs' reports of practice resources, and the frequency of body mass index assessment, counseling, referral for further evaluation/management, and monitoring of patients for energy balance care. Analysis. Descriptive statistics and logistic regression modeling were used. Results. More than 80% of PCPs reported having information resources on diet, physical activity, or weight control available in waiting/exam rooms, but fewer billed (45%), used reminder systems (< 30%), or received incentive payments (3%) for energy balance care. A total of 26% reported regularly assessing body mass index and always/often providing counseling as well as tracking patients for progress related to energy balance. In multivariate analyses, PCPs in practices with full electronic health records or those that bill for energy balance care provided this care more often and more comprehensively. There were strong specialty differences, with pediatricians more likely (odds ratio, 1.78; 95% confidence interval, 1.26–2.51) and obstetrician/gynecologists less likely (odds ratio, 0.28; 95% confidence interval, 0.17–0.44) than others to provide energy balance care. Conclusion. PCPs' practices are not well organized for providing energy balance care. Further research is needed to understand PCP care-related specialty differences.
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Inrig SJ, Tiro JA, Melhado TV, Argenbright KE, Craddock Lee SJ. Evaluating a De-Centralized Regional Delivery System for Breast Cancer Screening and Patient Navigation for the Rural Underserved. TEXAS PUBLIC HEALTH JOURNAL 2014; 66:25-34. [PMID: 28713882 PMCID: PMC5508746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
UNLABELLED Providing breast cancer screening services in rural areas is challenging due to the fractured nature of healthcare delivery systems and complex reimbursement mechanisms that create barriers to access for the under- and uninsured. Interventions that reduce structural barriers to mammography, like patient navigation programs, are effective and recommended, especially for minority and underserved women. Although the literature on rural healthcare is significant, the field lacks studies of adaptive service delivery models and rigorous evaluation of evidence-based programs that facilitate routine screening and appropriate follow-up across large geographic areas. OBJECTIVES To better understand how to implement a decentralized regional delivery "hub & spoke" model for rural breast cancer screening and patient navigation, we have designed a rigorous, structured, multi-level and mixed-methods evaluation based on Glasgow's RE-AIM model (Reach, Effectiveness, Adoption, Implementation, and Maintenance). METHODS AND DESIGN The program is comprised of three core components: 1) Outreach to underserved women by partnering with county organizations; 2) Navigation to guide patients through screening and appropriate follow-up; and 3) Centralized Reimbursement to coordinate funding for screening services through a central contract with Medicaid Breast and Cervical Cancer Services (BCCS). Using Glasgow's RE-AIM model, we will: 1) assess which counties have the resources and capacity to implement outreach and/or navigation components, 2) train partners in each county on how to implement components, and 3) monitor process and outcome measures in each county at regular intervals, providing booster training when needed. DISCUSSION This evaluation strategy will elucidate how the heterogeneity of rural county infrastructure impacts decentralized service delivery as a navigation program expands. In addition to increasing breast cancer screening access, our model improves and maintains time to diagnostic resolution and facilitates timely referral to local cancer treatment services. We offer this evaluation approach as an exemplar for scientific methods to evaluate the translation of evidence-based federal policy into sustainable health services delivery in a rural setting.
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Affiliation(s)
- Stephen J Inrig
- University of Texas Southwestern Medical Center, Department of Clinical Sciences, Dallas TX
- University of Texas Southwestern Harold C. Simmons Cancer Center, Dallas TX
| | - Jasmin A Tiro
- University of Texas Southwestern Medical Center, Department of Clinical Sciences, Dallas TX
- University of Texas Southwestern Harold C. Simmons Cancer Center, Dallas TX
| | - Trisha V Melhado
- University of Texas Southwestern Medical Center, Department of Clinical Sciences, Dallas TX
| | - Keith E Argenbright
- University of Texas Southwestern Medical Center, Department of Clinical Sciences, Dallas TX
- University of Texas Southwestern Harold C. Simmons Cancer Center, Dallas TX
- Moncrief Cancer Institute, Fort Worth, Texas
| | - Simon J Craddock Lee
- University of Texas Southwestern Medical Center, Department of Clinical Sciences, Dallas TX
- University of Texas Southwestern Harold C. Simmons Cancer Center, Dallas TX
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Liao CS, Lin YM, Chang HC, Chen YH, Chong LW, Chen CH, Lin YS, Yang KC, Shih CH. Application of quantitative estimates of fecal hemoglobin concentration for risk prediction of colorectal neoplasia. World J Gastroenterol 2013; 19:8366-8372. [PMID: 24363529 PMCID: PMC3857461 DOI: 10.3748/wjg.v19.i45.8366] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2013] [Revised: 08/15/2013] [Accepted: 08/29/2013] [Indexed: 02/06/2023] Open
Abstract
AIM: To determine the role of the fecal immunochemical test (FIT), used to evaluate fecal hemoglobin concentration, in the prediction of histological grade and risk of colorectal tumors.
METHODS: We enrolled 17881 individuals who attended the two-step colorectal cancer screening program in a single hospital between January 2010 and October 2011. Colonoscopy was recommended to the participants with an FIT of ≥ 12 ngHb/mL buffer. We classified colorectal lesions as cancer (C), advanced adenoma (AA), adenoma (A), and others (O) by their colonoscopic and histological findings. Multiple linear regression analysis adjusted for age and gender was used to determine the association between the FIT results and colorectal tumor grade. The risk of adenomatous neoplasia was estimated by calculating the positive predictive values for different FIT concentrations.
RESULTS: The positive rate of the FIT was 10.9% (1948/17881). The attendance rate for colonoscopy was 63.1% (1229/1948). The number of false positive results was 23. Of these 1229 cases, the numbers of O, A, AA, and C were 759, 221, 201, and 48, respectively. Regression analysis revealed a positive association between histological grade and FIT concentration (β = 0.088, P < 0.01). A significant log-linear relationship was found between the concentration and positive predictive value of the FIT for predicting colorectal tumors (R2 > 0.95, P < 0.001).
CONCLUSION: Higher FIT concentrations are associated with more advanced histological grades. Risk prediction for colorectal neoplasia based on individual FIT concentrations is significant and may help to improve the performance of screening programs.
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Choi KC, Chan HY, Chan DN, Lam WW, Chan CW, Ho SS, Cheng KK, Goggins WB, Shiu AT, So WK. The mediating role of health professionals' recommendation in the uptake of colorectal cancer testing among older Chinese adults. Int J Nurs Pract 2013; 20:170-178. [PMID: 24118258 DOI: 10.1111/ijn.12118] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
The purpose of this study is to examine the mediating effect of health professionals' recommendations on the relationship between the characteristics of older Chinese adults and the use of colorectal cancer testing. This was a cross-sectional population-based telephone survey. A total of 2004 Chinese adults aged 50 or above were recruited between 2 and 28 May 2007 to complete an anonymous telephone survey. The survey covered demographics, perceived health status and susceptibility to cancer, utilization of complementary medicine, family history of cancer, and cancer screening behaviour. The uptake of flexible sigmoidoscopy/colonoscopy was 12%, of which only 3.4% had been recommended by health professionals. The effects of gender, a history of serious disease, perceptions related to health status and visiting doctor regularly on the flexible sigmoidoscopy/colonoscopy uptake were mediated by a health professional's recommendation. A health professional's recommendation can be a catalyst for the decision of undergoing a colorectal cancer screening test in older adult people, in particular for those who are more health-conscious. As health professionals can play a crucial role in the development of successful population-based colorectal cancer screening program, efforts should be made to facilitate them in making recommendations for colorectal cancer screening to targeted high-risk group.
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Affiliation(s)
- Kai-Chow Choi
- The Nethersole School of Nursing, The Chinese University of Hong Kong, HKSAR, China
| | - Helen Yl Chan
- The Nethersole School of Nursing, The Chinese University of Hong Kong, HKSAR, China
| | - Dorothy Ns Chan
- The Nethersole School of Nursing, The Chinese University of Hong Kong, HKSAR, China
| | - Wendy Wt Lam
- Department of Community Medicine, The University of Hong Kong, HKSAR, China
| | - Carmen Wh Chan
- The Nethersole School of Nursing, The Chinese University of Hong Kong, HKSAR, China
| | - Simone Sm Ho
- The Nethersole School of Nursing, The Chinese University of Hong Kong, HKSAR, China
| | - Karis Kf Cheng
- Alice Lee Centre for Nursing Studies, National University of Singapore, Singapore
| | - William B Goggins
- School of Public Health and Primary Care, The Chinese University of Hong Kong, HKSAR, China
| | - Ann Ty Shiu
- The Nethersole School of Nursing, The Chinese University of Hong Kong, HKSAR, China
| | - Winnie Kw So
- The Nethersole School of Nursing, The Chinese University of Hong Kong, HKSAR, China
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