Physicians' approaches to recommending colorectal cancer screening: a qualitative study

Opportunities and Challenges When Using the Electronic Health Record for Practice-Integrated Patient-Facing Interventions: The e-Assist Colon Health Randomized Trial

Background

Even after a physician recommendation, many people remain unscreened for colorectal cancer (CRC). The proliferation of electronic health records (EHRs) and tethered online portals may afford new opportunities to embed patient-facing interventions within clinic workflows and engage patients following a physician recommendation for care. We evaluated the effectiveness of a patient-facing intervention designed to complement physician office-based recommendations for CRC screening.

Design

Using a 2-arm pragmatic, randomized clinical trial, we evaluated the intervention’s effect on CRC screening use as documented in the EHR (primary outcome) and the extent to which the intervention reached the target population. Trial participants were insured, aged 50 to 75 y, with a physician recommendation for CRC screening. Typical EHR functionalities, including patient registries, health maintenance flags, best practice alerts, and secure messaging, were used to support research-related activities and deliver the intervention to enrolled patients.

Results

A total of 1,825 adults consented to trial participation, of whom 78% completed a baseline survey and were exposed to the intervention. Most trial participants (>80%) indicated an intent to be screened on the baseline survey, and 65% were screened at follow-up, with no significant differences by study arm. One-third of eligible patients were sent a secure message. Among those, more than three-quarters accessed study material.

Conclusions

By leveraging common EHR functionalities, we integrated a patient-facing intervention within clinic workflows. Despite practice integration, the intervention did not improve screening use, likely in part due to portal-based interventions not reaching those for whom the intervention may be most effective.

Implications

Embedding patient-facing interventions within the EHR enabled practice integration but may minimize program effectiveness by missing important segments of the patient population.

Highlights

Understanding barriers and facilitators to participation in colorectal cancer screening: A French qualitative study

Based on the theory of social representations, this study aims to identify the main determinants to participation in colorectal cancer screening. Six focus groups (N = 29 participants belonging to the general population) were conducted, followed by a theoretical thematic analysis. Screening obstacles are a lack of test's accessibility, a low preoccupation for prevention and the negative image of colorectal cancer. Conversely, screening facilitators are the ease of the new test, being encouraged to get screened and appointment reminder. This study advances understanding of adherence to screening by addressing the beliefs and knowledge surrounding it.

'Simple and easy:' providers' and latinos' perceptions of the fecal immunochemical test (FIT) for colorectal cancer screening

Objective: Colorectal cancer (CRC) screening efforts have effectively reduced CRC morbidity and mortality, yet screening remains relatively low among Latinos. The study's purpose was to document the awareness/knowledge of Fecal Immunochemical Test (FIT) among Latinos, gain better understanding of patient and health care provider perceptions about FIT, and explore the feasibility of adoption/uptake.Design/Methods: The study was guided by qualitative, ethnography design and methods. Eight focus groups (FG) with patients who self-identified as Hispanic/Latino between 50-75 years of age and key informant interviews with providers (N = 10) were conducted followed by a brief demographic questionnaire.Results: Awareness levels varied based on prior screening experiences among patients and providers. Both patients and providers believed the FIT is simple and easy to use; although, a minority of patients expressed doubts about the efficacy of the FIT when compared to colonoscopy.Conclusions: Despite the increasing acceptance of the FIT among the health care community, a significant lag time still exists among our study's populations. Study findings speak to novelty of the FIT test among underserved populations and the health disparity gap between health innovations/discoveries. Increased awareness and education efforts about the efficacy coupled with information about its accessibility, ease, and user instructions may increase the adoption of FIT.

Community-Based Colorectal Cancer Screening in a Rural Population: Who Returns Fecal Immunochemical Test (FIT) Kits?

PURPOSE

To determine the return rate of community-delivered fecal immunochemical test (FIT) kits in a rural population and to identify significant predictors of returning kits.

METHODS

Residents were recruited in 8 rural Kentucky counties to enroll in the study and receive an FIT kit. Of 345 recruited, 82.0% returned an FIT kit from the point of distribution. These participants were compared to the remainder relative to age, sex, marital status, having an annual income below $15,000, not graduating from high school, not having a regular health care provider, not having health care coverage, being a current smoker, indicating current overweight or obese status, and a scale measure of fatalism pertaining to colorectal cancer. Predictors achieving significance at the bivariate level were entered into a stepwise logistic regression model to calculate adjusted OR and 95% CI.

FINDINGS

The return rate was 82.0%. In adjusted analyses, those indicating an annual income of less than $15,000 were 2.85 times more likely to return their kits (95% CI: 1.56-5.24; P < .001). Also, those not perceiving themselves to be overweight/obese were 1.95 times more likely to return their kits (95% CI: 1.07-3.55; P = .029).

CONCLUSIONS

An outreach-based colorectal cancer screening program in a rural population may yield high return rates. People with annual incomes below $15,000 and those not having perceptions of being overweight/obese may be particularly likely to return FIT kits.

Characterization of the Hispanic or latino population in health research: a systematic review

The size and diversity of the Hispanic population in the United States has dramatically increased, with vast implications for health research. We conducted a systematic review of the characterization of the Hispanic population in health research and described its implications. Relevant studies were identified by searches of PubMed, Embase Scopus, and Science/Social Sciences Citation Index from 2000 to 2011. 131 articles met criteria. 56% of the articles reported only "Hispanic" or "Latino" as the characteristic of the Hispanic research population while no other characteristics were reported. 29% of the articles reported language, 27% detailed country of origin and 2% provided the breakdown of race. There is great inconsistency in reported characteristics of Hispanics in health research. The lack of detailed characterization of this population ultimately creates roadblocks in translating evidence into practice when providing care to the large and increasingly diverse Hispanic population in the US.

Physician use of persuasion and colorectal cancer screening

The impact of patient-physician communication on subsequent patient behavior has rarely been evaluated in the context of colorectal cancer (CRC) screening discussions. We describe physicians' use of persuasive techniques when recommending CRC screening and evaluate its association with patients' subsequent adherence to screening. Audio recordings of N = 414 periodic health examinations were joined with screening use data from electronic medical records and pre-/post-visit patient surveys. The association between persuasion and screening was assessed using generalized estimating equations. According to observer ratings, primary care physicians frequently use persuasive techniques (63 %) when recommending CRC screening, most commonly argument or refutation. However, physician persuasion was not associated with subsequent screening adherence. Physician use of persuasion may be a common vehicle for information provision during CRC screening discussions; however, our results do not support the sole reliance on persuasive techniques if the goal is to improve adherence to recommended screening.

Comparing the effect of a decision aid plus patient navigation with usual care on colorectal cancer screening completion in vulnerable populations: study protocol for a randomized controlled trial

BACKGROUND

Screening can reduce colorectal cancer (CRC) incidence and mortality. However, screening is underutilized in vulnerable patient populations, particularly among Latinos. Patient-directed decision aids can increase CRC screening knowledge, self-efficacy, and intent; however, their effect on actual screening test completion tends to be modest. This is probably because decision aids do not address some of the patient-specific barriers that prevent successful completion of CRC screening in these populations. These individual barriers might be addressed though patient navigation interventions. This study will test a combined decision aid and patient navigator intervention on screening completion in diverse populations of vulnerable primary care patients.

METHODS/DESIGN

We will conduct a multisite, randomized controlled trial with patient-level randomization. Planned enrollment is 300 patients aged 50 to 75 years at average CRC risk presenting for appointments at two primary clinics in North Carolina and New Mexico. Intervention participants will view a video decision aid immediately before the clinic visit. The 14 to 16 minute video presents information about fecal occult blood tests and colonoscopy and will be viewed on a portable computer tablet in English or Spanish. Clinic-based patient navigators are bilingual and bicultural and will provide both face-to-face and telephone-based navigation. Control participants will view an unrelated food safety video and receive usual care. The primary outcome is completion of a CRC screening test at six months. Planned subgroup analyses include examining intervention effectiveness in Latinos, who will be oversampled. Secondarily, the trial will evaluate the intervention effects on knowledge of CRC screening, self-efficacy, intent, and patient-provider communication. The study will also examine whether patient ethnicity, acculturation, language preference, or health insurance status moderate the intervention effect on CRC screening.

DISCUSSION

This pragmatic randomized controlled trial will test a combined decision aid and patient navigator intervention targeting CRC screening completion. Findings from this trial may inform future interventions and implementation policies designed to promote CRC screening in vulnerable patient populations and to reduce screening disparities.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov NCT02054598.

Patient-physician colorectal cancer screening discussion content and patients' use of colorectal cancer screening

OBJECTIVE

The US Preventive Services Task Force recommends using the 5As (i.e., Assess, Advise, Agree, Assist and Arrange) when discussing preventive services. We evaluate the association of the 5As discussion during primary care office visits with patients' subsequent colorectal cancer (CRC) screening use.

METHODS

Audio-recordings of n=443 periodic health exams among insured patients aged 50-80 years and due for CRC screening were joined with pre-visit patient surveys and screening use data from an electronic medical record. Association of the 5As with CRC screening was assessed using generalized estimating equations.

RESULTS

93% of patients received a recommendation for screening (Advise) and 53% were screened in the following year. The likelihood of screening increased as the number of 5A steps increased: compared to patients whose visit contained no 5A step, those whose visit contained 1-2 steps (OR=2.96 [95% CI 1.16, 7.53]) and 3 or more steps (4.98 [95% CI 1.84, 13.44]) were significantly more likely to use screening.

CONCLUSIONS

Physician CRC screening recommendations that include recommended 5A steps are associated with increased patient adherence.

PRACTICE IMPLICATIONS

A CRC screening recommendation (Advise) that also describes patient eligibility (Assess) and provides help to obtain screening (Assist) may lead to improved adherence to CRC screening.

Making it work: health care provider perspectives on strategies to increase colorectal cancer screening in federally qualified health centers

Colorectal cancer screening (CRCS) rates are low among men and women who seek health care at federally qualified health centers (FQHCs). This study explores health care providers' perspectives about their patient's motivators and impediments to CRCS and receptivity to preparatory education. A mixed methods design consisting of in-depth interviews, focus groups, and a short survey is used in this study. The participants of this study are 17 health care providers practicing in FQHCs in the Tampa Bay area. Test-specific patient impediments and motivations were identified including fear of abnormal findings, importance of offering less invasive fecal occult blood tests, and need for patient-centered test-specific educational materials in clinics. Opportunities to improve provider practices were identified including providers' reliance on patients' report of symptoms as a cue to recommend CRCS and overemphasis of clinic-based guaiac stool tests. This study adds to the literature on CRCS test-specific motivators and impediments. Providers offered unique approaches for motivating patients to follow through with recommended CRCS and were receptive to in-clinic patient education. Findings readily inform the design of educational materials and interventions to increase CRCS in FQHCs.

From qualitative data to GP training on CRC screening

Colorectal cancer (CRC) is the third most common cancer worldwide. In France, although mass screening has been performed using the guaiac fecal occult blood test since 2008, the participation rate remains too low. Previous studies have explored the perspectives of doctors and patients as well as the performance of general practitioners (GPs) by recording and analyzing consultations in which patients came and asked for fecal occult blood test. Results indicated that improvement was needed in patient-centered communication. This research aims to develop educational material and training programs for GPs in order to enhance their communication with patients on CRC screening, based on data from two qualitative studies. Triangulation of all qualitative data was performed and discussed with communication experts in order to develop educational material and training programs based on the patient-centered clinical method. Two different scenarios were developed to improve communication with patients: one for a compliant patient and another for a noncompliant patient. Two videos were made featuring a doctor and a simulated patient. A two-sequence training program was built, including role-playing and presentation of the video followed by a discussion. The qualitative data helped us to produce a useful, relevant training program for GPs on CRC screening.

Considering culture in physician-- patient communication during colorectal cancer screening

Racial and ethnic disparities exist in both incidence and stage detection of colorectal cancer (CRC). We hypothesized that cultural practices (i.e., communication norms and expectations) influence patients' and their physicians' understanding and talk about CRC screening. We examined 44 videotaped observations of clinic visits that included a CRC screening recommendation and transcripts from semistructured interviews that doctors and patients separately completed following the visit. We found that interpersonal relationship themes such as power distance, trust, directness/ indirectness, and an ability to listen, as well as personal health beliefs, emerged as affecting patients' definitions of provider-patient effective communication. In addition, we found that in discordant physician-patient interactions (when each is from a different ethnic group), physicians did not solicit or address cultural barriers to CRC screening and patients did not volunteer culture-related concerns regarding CRC screening.