Patient-physician colorectal cancer screening discussions and screening use

Lifetime prevalence and correlates of colorectal cancer screening among low-income U.S. Veterans

PURPOSE

The Veterans Health Administration (VHA) is the largest integrated healthcare system in the U.S. While preventive healthcare services are high priority in the VHA, low-income U.S. Veterans experience adverse life circumstances that may negatively impact their access to these services. This study examined lifetime prevalence as well as demographic, socioeconomic, military-specific, and clinical correlates of colorectal cancer (CRC) screening among low-income U.S. Veterans ≥ 50 years of age.

METHODS

Cross-sectional data on 862 participants were analyzed from the 2021-2022 National Veteran Homeless and Other Poverty Experiences study.

RESULTS

Overall, 55.3% (95% confidence interval [CI] 51.3-59.3%) reported ever-receiving CRC-screening services. In a multivariable logistic regression model, never-receivers of CRC screening were twice as likely to reside outside of the Northeast, and more likely to be married (odds ratio [OR] = 1.86, 95% CI 1.02, 3.37), have BMI < 25 kg/m2 [vs. 25- < 30 kg/m2] (OR = 1.75, 95% CI 1.19, 2.58), or ≥ 1 chronic condition (OR = 1.46, 95% CI 1.06, 2.02). Never-receivers of CRC screening were less likely to be female (OR = 0.53, 95% CI 0.29, 0.96), aged 65-79y [vs. ≥ 80y] (OR = 0.61, 95% CI 0.40, 0.92), live in 5 + member households (OR = 0.33, 95% CI 0.13, 0.86), disabled (OR = 0.45, 0.22, 0.92), with purchased health insurance (OR = 0.56, 95% CI 0.33, 0.98), or report alcohol-use disorder (OR = 0.10, 95% CI 0.02, 0.49) and/or HIV/AIDS (OR = 0.28, 95% CI 0.12, 0.68).

CONCLUSION

Nearly 55% of low-income U.S. Veterans reported ever screening for CRC. Variations in CRC-screening behaviors according to veteran characteristics highlight potential disparities as well as opportunities for targeted behavioral interventions.

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

Colorectal Cancer Screening Prevalence and Adherence for the Cancer Prevention Project of Philadelphia (CAP3) Participants Who Self-Identify as Black

Introduction

Colorectal cancer is the third leading cause of cancer-related deaths among Black men and women. While colorectal cancer screening (CRCS) reduces mortality, research assessing within race CRCS differences is lacking. This study assessed CRCS prevalence and adherence to national screening recommendations and the association of region of birth with CRCS adherence, within a diverse Black population.

Methods

Data from age-eligible adults, 50–75 years, (N = 357) participating in an ongoing, cross-sectional study, was used to measure CRCS prevalence and adherence and region of birth (e.g., Caribbean-, African-, US-born). Prevalence and adherence were based on contemporaneous US Preventive Services Task Force guidelines. Descriptive statistics were calculated and adjusted prevalence and adherence proportions were calculated by region of birth. Adjusted logistic regression models were performed to assess the association between region of birth and overall CRCS and modality-specific adherence.

Results

Respondents were 69.5% female, 43.3% married/living with partner, and 38.4% had <$25,000 annual income. Overall, 78.2% reported past CRCS; however, stool test had the lowest prevalence overall (34.6%). Caribbean (95.0%) and African immigrants (90.2%) had higher prevalence of overall CRCS compared to US-born Blacks (59.2%) (p-value <0.001). African immigrants were five times more likely to be adherent to overall CRCS compared to US-born Blacks (OR = 5.25, 95% CI 1.34–20.6). Immigrants had higher odds of being adherent to colonoscopy (Caribbean OR = 6.84, 95% CI 1.49–31.5; African OR = 7.14, 95% CI 1.27–40.3) compared to US-born Blacks.

Conclusions

While Caribbean and African immigrants have higher prevalence and adherence of CRCS when compared US-born Blacks, CRCS is still sub-optimal in the Black population. Efforts to increase CRCS, specifically stool testing, within the Black population are warranted, with targeted interventions geared towards US-born Blacks.

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

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

Patient-Reported Needs Following a Referral for Colorectal Cancer Screening

INTRODUCTION

Patient-physician communication about colorectal cancer screening can affect screening use, but discussions often lack information that patients need for informed decision making and seldom address personal preferences or barriers. To address this gap, a series of patient focus groups was conducted to guide the development of an online, interactive decision support program. This article presents findings on patient information needs and barriers to colorectal cancer screening after receiving a screening recommendation from a physician, and their perspectives on using electronic patient portals as platforms for health-related decision support.

METHODS

Primary care patients with recent colonoscopy or stool testing orders were identified via the centralized data repository of a large Midwestern health system. Seven gender-stratified focus groups (N=45 participants) were convened between April and July 2016. Sessions were audio recorded, transcribed, coded, and analyzed for commonly expressed themes beginning in August 2016.

RESULTS

Findings reveal a consistent need for simple and clear information on colorectal cancer screening. Participants desired step-by-step explanations of the colonoscopy procedure and information about bowel preparation options/alternatives. The desired level of additional information varied: some patients wanted to know about and act on test options, whereas others preferred following their physician-recommended testing path. Fears and concerns were prevalent, particularly about colonoscopy, and patients reported challenges getting these concerns and their informational needs addressed. Finally, they expressed consistent support for using the patient portal to gather additional information from their physician.

CONCLUSIONS

Patient portals may offer an opportunity to build sustainable programs for decision support and assistance that are integrated with clinic workflows and processes.

Randomised trial to evaluate the effectiveness and impact of offering postvisit decision support and assistance in obtaining physician-recommended colorectal cancer screening: the e-assist: Colon Health study-a protocol study

INTRODUCTION

How to provide practice-integrated decision support to patients remains a challenge. We are testing the effectiveness of a practice-integrated programme targeting patients with a physician recommendation for colorectal cancer (CRC) screening.

METHODS AND ANALYSIS

In partnership with healthcare teams, we developed 'e-assist: Colon Health', a patient-targeted, postvisit CRC screening decision support programme. The programme is housed within an electronic health record (EHR)-embedded patient portal. It leverages a physician screening recommendation as the cue to action and uses the portal to enrol and intervene with patients. Programme content complements patient-physician discussions by encouraging screening, addressing common questions and assisting with barrier removal. For evaluation, we are using a randomised trial in which patients are randomised to receive e-assist: Colon Health or one of two controls (usual care plus or usual care). Trial participants are average-risk, aged 50-75 years, due for CRC screening and received a physician order for stool testing or colonoscopy. Effectiveness will be evaluated by comparing screening use, as documented in the EHR, between trial enrollees in the e-assist: Colon Health and usual care plus (CRC screening information receipt) groups. Secondary outcomes include patient-perceived benefits of, barriers to and support for CRC screening and patient-reported CRC screening intent. The usual care group will be used to estimate screening use without intervention and programme impact at the population level. Differences in outcomes by study arm will be estimated with hierarchical logit models where patients are nested within physicians.

ETHICS AND DISSEMINATION

All trial aspects have been approved by the Institutional Review Board of the health system in which the trial is being conducted. We will disseminate findings in diverse scientific venues and will target clinical and quality improvement audiences via other venues. The intervention could serve as a model for filling the gap between physician recommendations and patient action.

TRIAL REGISTRATION NUMBER

NCT02798224; Pre-results.

Engaging Patients in Decisions About Cancer Screening: Exploring the Decision Journey Through the Use of a Patient Portal

INTRODUCTION

Engaging patients to make informed choices is paramount but difficult in busy practices. This study sought to engage patients outside the clinical setting to better understand how they approach cancer screening decisions, including their primary concerns and their preferences for finalizing their decision.

METHODS

Twelve primary care practices offering patients an online personal health record invited eligible patients to complete a 17-item online interactive module. Among 11,458 registered users, invitations to complete the module were sent to adults aged 50-74 years who were overdue for colorectal cancer screening and to women aged 40-49 years and men aged 55-69 who had not undergone a recent mammogram or prostate-specific antigen test, respectively.

RESULTS

The module was started by 2,355 patients and completed by 903 patients. Most respondents (76.8%) knew they were eligible for screening. Preferred next steps were talking to the clinician (76.6%), reading/research (28.6%), and consulting trusted friends/family (16.4%). Priority topics included how much screening improves life expectancy, comparative test performance, and the prevalence/health risks of the cancer. Leading fears were getting cancer/delayed detection (79.2%), abnormal results (40.5%), and testing complications (39.1%), the last referring to false test results, medical complications, or unnecessary treatments. Men eligible for prostate-specific antigen screening were more likely than women eligible for mammography to express concerns about testing complications and to prioritize weighing pros and cons over gut feelings (p<0.05).

CONCLUSIONS

Although this sample was predisposed to screening, most patients wanted help in finalizing their decision. Many wanted to weigh the pros and cons and expressed fears of potential harms from screening. Understanding how patients approach decisions may help design more effective engagement strategies.

A pre-post study testing a lung cancer screening decision aid in primary care

BACKGROUND

The United States Preventive Services Task Force (USPSTF) issued recommendations for older, heavy lifetime smokers to complete annual low-dose computed tomography (LDCT) scans of the chest as screening for lung cancer. The USPSTF recommends and the Centers for Medicare and Medicaid Services require shared decision making using a decision aid for lung cancer screening with annual LDCT. Little is known about how decision aids affect screening knowledge, preferences, and behavior. Thus, we tested a lung cancer screening decision aid video in screening-eligible primary care patients.

METHODS

We conducted a single-group study with surveys before and after decision aid viewing and medical record review at 3 months. Participants were active patients of a large US academic primary care practice who were current or former smokers, ages 55-80 years, and eligible for screening based on current screening guidelines. Outcomes assessed pre-post decision aid viewing were screening-related knowledge score (9 items about screening-related harms of false positives and overdiagnosis, likelihood of benefit; score range = 0-9) and preference (preferred screening vs. not). Screening behavior measures, assessed via chart review, included provider visits, screening discussion, LDCT ordering, and LDCT completion within 3 months.

RESULTS

Among 50 participants, knowledge increased from pre- to post-decision aid viewing (mean = 2.6 vs. 5.5, difference = 2.8; 95% CI 2.1, 3.6, p < 0.001). Preferences across the overall sample remained similar such that 54% preferred screening at baseline and 50% after viewing; however, 28% of participants changed their preference (to or away from screening) from baseline to after viewing. We assessed screening behavior for 36 participants who had a primary care visit during the 3-month period following enrollment. Eighteen of 36 preferred screening after decision aid viewing. Of these 18, 10 discussed screening, 8 had a test ordered, and 6 completed LDCT. Among the 18 who preferred no screening, 7 discussed screening, 5 had a test ordered, and 4 completed LDCT.

CONCLUSIONS

In primary care patients, a lung cancer screening decision aid improved knowledge regarding screening-related benefits and harms. Screening preferences and behavior were heterogeneous.

TRIAL REGISTRATION

This study is registered at www.clinicaltrials.gov . NCT03077230 (registered retrospectively,November 22, 2016).

Fecal immunological blood test is more appealing than the guaiac-based test for colorectal cancer screening

BACKGROUND

The reasons for participation in fecal immunological testing (FIT) of subjects who were previously non-respondents to guaiac fecal occult blood testing (g-FOBT) have not been assessed.

POPULATION AND METHODS

We aimed to determine the reasons for current compliance with FIT among non-responders to g-FOBT, termed "converts‿, in a French district. A questionnaire was returned by 170 converts aged from 55 to 75 years (response rate 75.2% after exclusions).

RESULTS

The major barriers to participation in screening with g-FOBT were test-related: the test was perceived as complicated (24%) and it required three consecutive stools (28%). Among the test-related major determinants of FIT compliance was the perception that the test was less complicated than previous test (30%) and that a unique stool sample was required (29%). Among the non-test related major determinants of FIT compliance were the perception that the general practitioner was more convincing (31%) and the feeling to be more concerned because of age (21%). The reasons for compliance among converts did not differ according to age, sex, and rural or urban residence.

CONCLUSIONS

Our study demonstrated that the simplicity of FIT and the endorsement of practitioners were both major motivations for FIT compliance among non-respondents in at least two previous consecutive campaigns.

Patient-provider discussions about lung cancer screening pre- and post-guidelines: Health Information National Trends Survey (HINTS)

OBJECTIVE

In 2013, the USPSTF issued a Grade B recommendation that long-term current and former smokers receive lung cancer screening. Shared decision-making is important for individuals considering screening, and patient-provider discussions an essential component of the process. We examined prevalence and predictors of lung cancer screening discussions pre- and post-USPSTF guidelines.

METHODS

Data were obtained from two cycles of the Health Information National Trends Survey (2012; 2014). The analyzed sample comprised screening-eligible current and former smokers with no personal history of lung cancer (n=746 in 2012; n=795 in 2014). Descriptive and multiple logistic regression analyses were conducted; patient-reported discussion about lung cancer screening with provider was the outcome of interest.

RESULTS

Contrary to expectations, patient-provider discussions about lung cancer screening were more prevalent pre-guideline, but overall patient-provider discussions were low in both years (17% in 2012; 10% in 2014). Current smokers were more likely to have had a discussion than former smokers. Significant predictors of patient-provider discussions included family history of cancer and having healthcare coverage.

CONCLUSIONS

The prevalence of patient-provider discussions about lung cancer screening is suboptimal.

PRACTICE IMPLICATIONS

There is a critical need for patient and provider education about shared decision-making and its importance in cancer screening decisions.

Colorectal Cancer Screening in Vulnerable Patients: Promoting Informed and Shared Decisions

INTRODUCTION

Low-income, low-literacy, limited English-proficient populations have low colorectal cancer (CRC) screening rates and experience poor patient-provider communication and decision-making processes around screening. The purpose of this study was to test the effect of a CRC screening decision aid on screening-related communication and decision making in primary care visits.

STUDY DESIGN

RCT with data collected from patients at baseline and immediately after the provider encounter.

SETTING/PARTICIPANTS

Patients aged 50-75 years, due for CRC screening, were recruited from two safety net clinics in North Carolina and New Mexico (data collection, January 2014-September 2015; analysis, 2015).

INTERVENTION

Participants viewed a CRC screening decision aid or a food safety (control) video immediately before their provider encounter.

MAIN OUTCOME MEASURES

CRC screening-related knowledge, discussion, intent, test preferences, and test ordering.

RESULTS

The study population (N=262) had a mean age of 58.3 years and was 66% female, 61% Latino, 17% non-Latino black, and 16% non-Latino white. Among Latino participants, 71% preferred Spanish. Compared with controls, intervention participants had greater screening-related knowledge (on average 4.6 vs 2.8 of six knowledge items correct, adjusted difference [AD]=1.8, 95% CI=1.5, 2.1) and were more likely to report screening discussion (71.0% vs 45.0%, AD=26.1%, 95% CI=14.3%, 38.0%) and high screening intent (93.1% vs 84.7%, AD=9.0%, 95% CI=2.0%, 16.0%). Intervention participants were more likely to indicate a specific screening test preference (93.1% vs 68.0%, AD=26.5%, 95% CI=17.2%, 35.8%) and to report having a test ordered (56.5% vs 32.1%, AD=25.8%, 95% CI=14.4%, 37.2%).

CONCLUSIONS

Viewing a CRC screening decision aid before a primary care encounter improves knowledge and shared decision making around screening in a racially, ethnically, and linguistically diverse safety net clinic population.

TRIAL REGISTRATION

This study is registered at www.clinicaltrials.gov NCT02054598.

Analysis of participant satisfaction in the Barcelona colorectal cancer screening programme: Positive evaluation of the community pharmacy

BACKGROUND AND OBJECTIVE

Population-based bowel screening programmes with faecal occult blood (FOB) tests need to achieve high uptake rates and offer quality services. We invited participants in the Barcelona Programme to complete a satisfaction survey, in order to explore factors influencing uptake and respondents' opinion and satisfaction with each step of the screening process.

MATERIAL AND METHOD

Telephone survey using an ad hoc questionnaire (see annex) administered to a final sample of 1189 people: 310 non-participants in the programme (NoP), 553 participants with a negative test result (PNeg), and 326 participants with a positive result (PPos).

RESULTS

High scores were obtained for the clarity of the information provided by the programme (mean 8.9 on a scale 0-10), and for the accessibility and attention at the pharmacy as well as its role as the point for collection and return of FOB test cards (mean >9.3). Aspects that were not so highly rated were: preparation for the colonoscopy (41.6% reported quite a lot or a lot of discomfort), and to a lesser extent telephone accessibility (27.1% reported some difficulties). Participants also expressed concern about receiving a positive test result by telephone (78.9% reported some concern).

CONCLUSIONS

Respondents' opinion of the programme was positive overall, and supports the pharmacy as the point for distributing and collecting FOB test cards, as well as the role of the pharmacist in the context of the programme. Some aspects of the screening process will be reviewed in order to improve participant satisfaction and eventually increase uptake.

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

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

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.

Managed care patients' preferences, physician recommendations, and colon cancer screening

Objective To evaluate associations between patients' preferences for attributes of different colorectal (CRC) screening modalities, physician CRC screening recommendations during periodic health exams, and subsequent utilization of screening 12 months later in a large health maintenance organization (HMO). Study Design Multi-method study including baseline surveys from average-risk HMO members joined with audio recordings of 415 periodic health exams (PHEs) and electronic medical record (EMR) data. Methods Patient ratings of test attributes were used to create an algorithm reflecting type and strength of CRC screening modality preference at baseline. Physician recommendations were obtained from audio recordings. Attribute-based test preferences and physician recommendations were compared with CRC test use using chisquare tests. Associations between attribute-based preferences and physician recommendations were assessed using logistic regression. Results Based on attribute rankings, most participants had a weak preference for colonoscopy (COL) (41%), an unclear preference (22.4%), or a weak preference for fecal occult blood testing (FOBT) (18.6%). About half (56%) of patients were screened at 12 months and there was no statistical association between attribute preferences and type of test received. Patients were significantly more likely to receive a recommendation including a test other than COL when they had an attribute-based test preference for FOBT (odds ratio [OR]: 2.17; 95% CI, 1.26-3.71; P < .01). Conclusions CRC screening test use in this large HMO was generally low. It was not associated with patients' preferences for different attributes of CRC screening tests but was associated with physician recommendations. Physicians may have better success in getting patients to screen if they consider preferences for test attributes.

Screening strategies for colorectal cancer in asymptomatic adults

This article provides an update for the primary care community on the evidence and recommendations for colorectal cancer screening in the adult population without symptoms at average and increased risk, excluding patients with high-risk genetic syndromes. The current and possible new screening strategies are reviewed, along with clinical wisdom related to the implementation of each method.

Provider perspectives on the utility of a colorectal cancer screening decision aid for facilitating shared decision making

BACKGROUND

Decision aids for colorectal cancer (CRC) screening have been shown to enable patients to identify a preferred screening option, but the extent to which such tools facilitate shared decision making (SDM) from the perspective of the provider is less well established.

OBJECTIVE

Our goal was to elicit provider feedback regarding the impact of a CRC screening decision aid on SDM in the primary care setting.

METHODS

Cross-sectional survey.

PARTICIPANTS

Primary care providers participating in a clinical trial evaluating the impact of a novel CRC screening decision aid on SDM and adherence.

MAIN OUTCOMES

Perceptions of the impact of the tool on decision-making and implementation issues.

RESULTS

Twenty-nine of 42 (71%) eligible providers responded, including 27 internists and two nurse practitioners. The majority (>60%) felt that use of the tool complimented their usual approach, increased patient knowledge, helped patients identify a preferred screening option, improved the quality of decision making, saved time and increased patients' desire to get screened. Respondents were more neutral is their assessment of whether the tool improved the overall quality of the patient visit or patient satisfaction. Fewer than 50% felt that the tool would be easy to implement into their practices or that it would be widely used by their colleagues.

CONCLUSION

Decision aids for CRC screening can improve the quality and efficiency of SDM from the provider perspective but future use is likely to depend on the extent to which barriers to implementation can be addressed.

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.

Cultural and linguistic adaptation of a multimedia colorectal cancer screening decision aid for Spanish-speaking Latinos

As the United States becomes more linguistically and culturally diverse, there is a need for effective health communication interventions that target diverse, vulnerable populations, including Latinos. To address such disparities, health communication interventionists often face the challenge to adapt existing interventions from English into Spanish in a way that retains essential elements of the original intervention while also addressing the linguistic needs and cultural perspectives of the target population. The authors describe the conceptual framework, context, rationale, methods, and findings of a formative research process used in creating a Spanish-language version of an evidence-based (English language) multimedia colorectal cancer screening decision aid. The multistep process included identification of essential elements of the existing intervention, literature review, assessment of the regional context and engagement of key stakeholders, and solicitation of direct input from target population. The authors integrated these findings in the creation of the new adapted intervention. They describe how they used this process to identify and integrate sociocultural themes such as personalism (personalismo), familism (familismo), fear (miedo), embarrassment (verguenza), power distance (respeto), machismo, and trust (confianza) into the Spanish-language decision aid.

Barriers and facilitators to adherence to screening colonoscopy among African-Americans: a mixed-methods analysis

This mixed-methods study reports barriers and facilitators to screening colonoscopy among inner-city African-Americans. A purposive sample of 29 African-Americans ≥ 50 years old with average risk of colorectal cancer (CRC) was recruited from CRC education programs in an urban setting (June 2011-April 2012). A demographic survey collected quantitative data (e.g., socioeconomic status), and a semi-structured interview assessed qualitative data (e.g., perspectives of colonoscopies). Sample and between-group analyses were conducted using descriptive statistics and content analysis of quantitative and qualitative data, respectively. The sample consisted of 17 people who completed a colonoscopy and 12 who had not. Mean age was 68 years; 79 % completed at least high school, and all had health care coverage and had visited a physician within the last year. Physician recommendation was prevalent among both groups (15/17 in completers vs. 8/12 in non-completers) and thus did not fully explain the differences in adherence. The greatest barrier for the non-colonoscopy group was lack of knowledge about the importance of screening while the commonest facilitator for the colonoscopy group was physician recommendation. Improved knowledge about colonoscopies is a significant facilitator to adherence, while physician recommendation was not significantly different between groups. Promotion of screening colonoscopies by both physicians and community programs has the potential to improve adherence rates in the African-American population.

Decision Aid to Technologically Enhance Shared decision making (DATES): study protocol for a randomized controlled trial

BACKGROUND

Clinicians face challenges in promoting colorectal cancer screening due to multiple competing demands. A decision aid that clarifies patient preferences and improves decision quality can aid shared decision making and be effective at increasing colorectal cancer screening rates. However, exactly how such an intervention improves shared decision making is unclear. This study, funded by the National Cancer Institute, seeks to provide detailed understanding of how an interactive decision aid that elicits patient's risks and preferences impacts patient-clinician communication and shared decision making, and ultimately colorectal cancer screening adherence.

METHODS/DESIGN

This is a two-armed single-blinded randomized controlled trial with the target of 300 patients per arm. The setting is eleven community and three academic primary care practices in Metro Detroit. Patients are men and women aged between 50 and 75 years who are not up to date on colorectal cancer screening. ColoDATES Web (intervention arm), a decision aid that incorporates interactive personal risk assessment and preference clarification tools, is compared to a non-interactive website that matches ColoDATES Web in content but does not contain interactive tools (control arm). Primary outcomes are patient uptake of colorectal cancer screening; patient decision quality (knowledge, preference clarification, intent); clinician's degree of shared decision making; and patient-clinician concordance in the screening test chosen. Secondary outcome incorporates a Structural Equation Modeling approach to understand the mechanism of the causal pathway and test the validity of the proposed conceptual model based on Theory of Planned Behavior. Clinicians and those performing the analysis are blinded to arms.

DISCUSSION

The central hypothesis is that ColoDATES Web will improve colorectal cancer screening adherence through improvement in patient behavioral factors, shared decision making between the patient and the clinician, and concordance between the patient's and clinician's preferred colorectal cancer screening test. The results of this study will be among the first to examine the effect of a real-time preference assessment exercise on colorectal cancer screening and mediators, and, in doing so, will shed light on the patient-clinician communication and shared decision making 'black box' that currently exists between the delivery of decision aids to patients and subsequent patient behavior.

TRIAL REGISTRATION

ClinicalTrials.gov ID NCT01514786.

Self-reported barriers to colorectal cancer screening in a racially diverse, low-income study population

Colorectal cancer (CRC) screening is underutilized, especially in low income, high minority populations. We examined the effect test-specific barriers have on colonoscopy and fecal immunochemical test (FIT) completion, what rationales are given for non-completion, and what "switch" patterns exist when participants are allowed to switch from one test to another. Low income adults who were not up-to-date with CRC screening guidelines were recruited from safety-net clinics and offered colonoscopy or FIT (n = 418). Follow up telephone surveys assessed test-specific barriers. Test completion was determined from patient medical records. For subjects who desired colonoscopy at baseline, finding a time to come in and transportation applied more to non-completers than completers (p = 0.001 and p < 0.001, respectively). For participants who initially wanted FIT, keeping track of cards, never putting stool on cards, and not remembering to mail cards back applied more to non-completers than completers (p = 0.003, p = 0.006, and p < 0.001, respectively). The most common rationale given for not completing screening was a desire for the other screening modality: 7 % of patients who initially preferred screening by FIT completed colonoscopy, while 8 % of patients who initially preferred screening by colonoscopy completed FIT. We conclude that test-specific barriers apply more to subjects who did not complete CRC screening. As a common rationale for test non-completion is a desire to receive a different screening modality, our findings suggest screening rates could be increased by giving patients the opportunity to switch tests after an initial choice is made.

Risk assessment and clinical decision making for colorectal cancer screening

BACKGROUND

Shared decision making (SDM) related to test preference has been advocated as a potentially effective strategy for increasing adherence to colorectal cancer (CRC) screening, yet primary care providers (PCPs) are often reluctant to comply with patient preferences if they differ from their own. Risk stratification advanced colorectal neoplasia (ACN) provides a rational strategy for reconciling these differences.

OBJECTIVE

To assess the importance of risk stratification in PCP decision making related to test preference for average-risk patients and receptivity to use of an electronic risk assessment tool for ACN to facilitate SDM.

DESIGN

Mixed methods, including qualitative key informant interviews and a cross-sectional survey.

PARTICIPANTS

PCPs at an urban, academic safety-net institution.

MAIN MEASURES

Screening preferences, factors influencing patient recommendations and receptivity to use of a risk stratification tool.

KEY RESULTS

Nine PCPs participated in interviews and 57 completed the survey. Despite an overwhelming preference for colonoscopy by 95% of respondents, patient risk (67%) and patient preferences (63%) were more influential in their decision making than patient comorbidities (31%; P < 0.001). Age was the single most influential risk factor (excluding family history), with <20% of respondents choosing factors other than age. Most respondents reported that they would be likely to use a risk stratification tool in their practice either 'often' (43%) or sometimes (53%).

CONCLUSIONS

Risk stratification was perceived to be important in clinical decision making, yet few providers considered risk factors other than age for average-risk patients. Providers were receptive to the use of a risk assessment tool for ACN when recommending an appropriate screening test for select patients.

Shared decision-making about colorectal cancer screening: a conceptual framework to guide research

OBJECTIVE

To develop a conceptual framework to guide research on shared decision-making about colorectal cancer (CRC) screening among persons at average risk and their providers.

METHODS

Based upon a comprehensive review of empirical literature and relevant theories, a conceptual framework was developed that incorporated patient characteristics, cultural beliefs, provider/health care system variables, health belief/knowledge/stage of adoption variables, and shared decision-making between patients and providers that may predict behavior. Relationships among concepts in the framework, shared decision-making process and outcomes, and CRC screening behavior were proposed. Directions for future research were presented.

RESULTS

Many of the concepts in the proposed framework have been examined in prior research. However, these elements have not been combined previously to explain shared decision-making about CRC screening.

CONCLUSION

Research is needed to test the proposed relationships and hypotheses and to refine the framework.

PRACTICE IMPLICATIONS

Findings from future research guided by the proposed framework may inform clinical practice to facilitate shared decision-making about CRC screening.

More comprehensive discussion of CRC screening associated with higher screening

OBJECTIVES

Examine association of comprehensiveness of colorectal cancer (CRC) screening discussion by primary care physicians (PCPs) with completion of CRC screening.

STUDY DESIGN

Observational study in Kaiser Permanente Northwest, a group-model health maintenance organization.

METHODS

A total of 883 participants overdue for CRC screening received an automated telephone call (ATC) between April and June 2009 encouraging CRC screening. Between January and March 2010, participants completed a survey on PCPs' discussion of CRC screening and patient beliefs regarding screening.

PRIMARY OUTCOME MEASURE

receipt of CRC screening (assessed by electronic medical record [EMR], 9 months after ATC). Primary independent variable: comprehensiveness of CRC screening discussion by PCPs (7-item scale). Secondary independent variables: perceived benefits of screening (4-item scale assessing respondents' agreement with benefits of timely screening) and primary care utilization (EMR; 9 months after ATC). The independent association of variables with CRC screening was assessed with logistic regression.

RESULTS

Average scores for comprehensiveness of CRC discussion and perceived benefits were 0.4 (range 0-1) and 4.0 (range 1-5), respectively. A total of 28.2% (n = 249) completed screening, 84% of whom had survey assessments after their screening date. Of screeners, 95.2% completed the fecal immunochemical test. More comprehensive discussion of CRC screening was associated with increased screening (odds ratio [OR] = 1.51, 95% confidence interval [CI] = 1.03-2.21). Higher perceived benefits (OR = 1.46, 95% CI = 1.13-1.90) and 1 or more PCP visits (OR = 5.82, 95% CI = 3.87-8.74) were also associated with increased screening.

CONCLUSIONS

More comprehensive discussion of CRC screening was independently associated with increased CRC screening. Primary care utilization was even more strongly associated with CRC screening, irrespective of discussion of CRC screening.

Using population data to reduce disparities in colorectal cancer screening, Arkansas, 2006

Introduction

Colorectal cancer is a common disease, and incidence and death rates are higher in medically underserved populations. The colorectal cancer death rate in Arkansas exceeds the national rate. The objective of this study was to examine population characteristics relevant to the design and implementation of a state-sponsored colorectal cancer screening program that is responsive to medically underserved populations.

Methods

Trained interviewers in 2006 conducted a random-digit–dialed telephone survey comprising items selected from the Health Information National Trends Survey to characterize demographic factors, health care variables, and colorectal screening history in a sample (n = 2,021) representative of the Arkansas population. Univariate and multivariate analyses identified associations among population characteristics and screening status.

Results

Participants who were aged 50 to 64, who did not have health insurance, or who had an annual household income of $15,000 or less were significantly less likely than their counterparts to be in compliance with screening guidelines. Those who reported having a health care provider, having 5 or more health care visits during the past year, and receiving physician advice for colorectal screening were more likely to be in compliance with screening guidelines. Although a larger percentage of white participants were in compliance with screening guidelines, blacks had higher screening rates than whites when we controlled for screening advice.

Conclusion

Survey results informed efforts to decrease disparities in colorectal cancer screening in Arkansas. Efforts should focus on reimbursing providers and patients for screening costs, encouraging the use of physicians as a point of entry to screening programs, and promoting a balanced approach (ie, multiple options) to screening recommendations. Our methods established a model for developing screening programs for medically underserved populations.

Change to FIT increased CRC screening rates: evaluation of a US screening outreach program

OBJECTIVES

To compare completion rates of colorectal cancer screening tests within a health maintenance organization before and after widespread adoption of the fecal immunochemical test (FIT).

STUDY DESIGN

Retrospective cohort study.

METHODS

Using electronic medical records of 113,901 patients eligible for colorectal cancer screening, we examined test completion during 2 successive time periods among those who received an automated screening outreach call. The time periods were: 1) the "guaiac fecal occult blood test (gFOBT) era," a 15-month period during which only gFOBT was routinely offered, and 2) a 9-month "FIT era," when only a new FIT was routinely offered. In addition to analyzing completion rates, we analyzed the impact of practice-level variables and patient-level variables on overall screening completion during the 2 different observation periods.

RESULTS

The change from gFOBT to FIT in an integrated care delivery system increased the likelihood of screening completion by 7.7% overall, and the likelihood of screening with a fecal test by 8.9%. The greatest gains in screening completion using FIT were among women and elderly patients. Completion of FIT was not as strongly associated with medical office visits or with having a primary care provider as was screening with gFOBT.

CONCLUSIONS

Adoption of FIT within an integrated care system increased completion of colon cancer screening tests within a 9-month assessment period, compared with a previous 15-month gFOBT era. Higher completion rates of the FIT may allow for more effective dissemination of programs to increase colorectal cancer screening through centralized outreach programs.

Patient-provider discussions about colorectal cancer screening: who initiates elements of informed decision making?

BACKGROUND

Colorectal cancer (CRC) screening rates remain low among low-income minority populations.

OBJECTIVE

To evaluate informed decision making (IDM) elements about CRC screening among low-income minority patients.

DESIGN

Observational data were collected as part of a patient-level randomized controlled trial to improve CRC screening rates. Medical visits (November 2007 to May 2010) were audio-taped and coded for IDM elements about CRC screening. Near the end of the study one provider refused recording of patients' visits (33 of 270 patients). Among all patients in the trial, agreement to be audio taped was 43.5 % (103/237). Evaluable patient (n = 100) visits were assessed for CRC screening discussion occurrence, IDM elements, and who initiated discussion of each IDM element.

PARTICIPANTS

Patients were African American (72.2 %), female (63.7 %), with annual household incomes <$20,000 (60.7 %), without health insurance (57.0 %), and limited health literacy (53.7 %).

KEY RESULTS

Although CRC screening was mentioned during 48 (48 %) visits, no further discussion about screening occurred in 23 visits (19 times mentioned by the participant with no response from providers). During any visit, the maximum number of IDM elements was five; however, only two visits included five elements. The most common IDM element discussed in addition to the nature of the decision was the assessment of the patient's understanding in 16 (33.3 %) of the visits that included a CRC discussion.

CONCLUSIONS

A patient activation intervention initiated CRC screening discussions with health care providers; however, limited IDM occurred about CRC screening during medical visits of minority and low-income patients.

Bringing an organizational perspective to the optimal number of colorectal cancer screening options debate

Improving colorectal cancer (CRC) screening rates represents a challenge for primary care providers. Some have argued that offering a choice of CRC screening modes to patients will improve the currently low adherence rates. Others have raised concerns that offering numerous CRC screening options in practice could overwhelm patients and thus dampen enthusiasm for screening. In this article we assemble evidence to critically evaluate the relative merit of these opposing views. We find little evidence to support the hypothesis that the number of options offered will affect adherence (either positively or negatively), or that expanding the modalities offered beyond FOBT and colonoscopy will improve patient satisfaction. Therefore, we assert future decisions about the number of CRC screening modes to offer would more productively be focused on considerations such as what benefit the health-care organization would derive from offering additional modes, and how this change would affect other critical components of a successful screening program such as timely diagnosis. In light of these organizational level considerations, we agree with the assertion made by others that a screening program limited to FOBT and colonoscopy is likely to be ideal in most settings.

Primary care colorectal cancer screening recommendation patterns: associated factors and screening outcomes

BACKGROUND

The relationship of a primary care provider's (PCP's) colorectal cancer (CRC) screening strategies to completion of screening is poorly understood.

OBJECTIVE

To describe PCP test recommendation patterns and associated factors and their relationship to patient test completion.

DESIGN

This cross-sectional study used a PCP survey, in-depth PCP interviews, and electronic medical records.

SETTING

Kaiser Permanente Northwest health maintenance organization.

PARTICIPANTS

Participants included 132 PCPs and 49,259 eligible patients aged 51 to 75.

MEASUREMENTS

The authors grouped PCPs by patterns of CRC screening recommendations based on reported frequency of recommending fecal occult blood testing (FOBT), flexible sigmoidoscopy (FS), and colonoscopy. They then compared PCP demographics, reported CRC screening test influences, concerns, decision-making and counseling processes, and actual rates of patient CRC screening completion by PCP group.

RESULTS

The authors identified 4 CRC screening recommendation groups: a "balanced" group (n = 54; 40.9%) that recommended the tests nearly equally, an FOBT group (n = 31; 23.5%) that largely recommended FOBT, an FOBT + FS group (n = 25; 18.9%), and a colonoscopy + FOBT group (n = 22; 16.7%) that recommended these tests nearly equally. Internal medicine (v. family medicine) PCPs were more common in groups more frequently recommending endoscopy. The FOBT and FOBT + FS groups were most influenced by clinical guidelines. Groups recommending more endoscopy were most concerned that FOBT generates a relatively high number of false positives and FOBT can miss cancers. The FOBT and FOBT + FS groups were more likely to recommend a specific screening strategy compared to the colonoscopy + FOBT and balanced groups, which were more likely to let the patient decide. CRC screening rates were 63.9% balanced, 62.9% FOBT, 61.7% FOBT + FS, and 62.2% colonoscopy + FOBT; rates did not differ significantly by group.

LIMITATIONS

Small numbers within PCP groups.

CONCLUSIONS

Specialty, the influence of guidelines, test concerns, and the "jointness" of the test selection decision distinguished CRC screening recommendation patterns. All patterns were associated with similar overall screening rates.

Patient-physician colorectal cancer screening discussions: delivery of the 5A's in practice

BACKGROUND

The U.S. Preventive Services Task Force advocates use of a 5A's framework (assess, advise, agree, assist, and arrange) for preventive health recommendations.

PURPOSE

To describe 5A content of patient-physician colorectal cancer (CRC) screening discussions and physician-recommended screening modality and to test if these vary by whether patient previously received screening recommendation.

METHODS

Direct observation of periodic health examinations in 2007-2009 among average-risk primary care patients aged 50-80 years due for screening. Qualitative content analyses conducted 2008-2010 used to code office visit audio-recordings for 5A and other discussion content.

RESULTS

Among study-eligible visits (N=415), 59% contained assistance (i.e., help scheduling colonoscopy or delivery of stool cards), but the assess, advise, and agree steps were rarely comprehensively provided (1%-21%), and only 3% included the last step, arrange follow-up. Almost all physicians endorsed screening via colonoscopy (99%), either alone (69%) or in combination with other tests (30%). Patients nonadherent to a prior physician screening recommendation (31%) were less likely to have the reason(s) for screening discussed (37% vs 65%) or be told the endoscopy clinic would call them for scheduling (19% vs 27%), and more likely to have fecal occult blood testing (FOBT) alone (34% vs 25%) or FOBT and colonoscopy recommended (24% vs 14%), and a screening plan negotiated (21% vs 14%). Significance level is p<0.05 for all contrasts.

CONCLUSIONS

Most patients due for CRC screening discuss screening with their physician, but with limited application of the 5A's approach. Opportunities to improve CRC screening decision-making are great, particularly among patients who are nonadherent to a prior recommendation from a physician.

Preferences for colorectal cancer screening tests and screening test use in a large multispecialty primary care practice

BACKGROUND

The purpose of this study was to identify factors associated with colorectal cancer (CRC) screening test preference and examine the association between test preference and test completed.

METHODS

Patients (n = 1224) were 50-70 years, at average CRC risk, and overdue for screening. Outcome variables were preference for fecal occult blood test (FOBT), colonoscopy (COL), sigmoidoscopy (SIG), or barium enema (BE), measured by telephone survey, and concordance between test preference and test completed assessed using medical records.

RESULTS

Thirty-five percent preferred FOBT, 41.1% COL, 12.7% SIG, and 5.7% BE. Preference for SIG or COL was associated with having a physician recommendation, greater screening readiness, test-specific self-efficacy, greater CRC worry, and perceived pros of screening. Preference for FOBT was associated with self-efficacy for doing FOBT. Participants who preferred COL were more likely to complete COL compared with those who preferred another test. Of those screened, only 50% received their preferred test. Those not receiving their preferred test most often received COL (52%).

CONCLUSIONS

Lack of concordance between patient preference and test completed suggests that patients' preferences are not well incorporated into screening discussions and test decisions, which could contribute to low screening uptake. Physicians should acknowledge patients' preferences when discussing test options and making recommendations, which may increase patients' receptivity to screening.

A randomized controlled trial of a tailored interactive computer-delivered intervention to promote colorectal cancer screening: sometimes more is just the same

BACKGROUND

There have been few studies of tailored interventions to promote colorectal cancer (CRC) screening.

PURPOSE

We conducted a randomized trial of a tailored, interactive intervention to increase CRC screening.

METHODS

Patients 50-70 years completed a baseline survey, were randomized to one of three groups, and attended a wellness exam after being exposed to a tailored intervention about CRC screening (tailored group), a public web site about CRC screening (web site group), or no intervention (survey-only group). The primary outcome was completion of any recommended CRC screening by 6 months.

RESULTS

There was no statistically significant difference in screening by 6 months: 30%, 31%, and 28% of the survey-only, web site, and tailored groups were screened. Exposure to the tailored intervention was associated with increased knowledge and CRC screening self-efficacy at 2 weeks and 6 months. Family history, prior screening, stage of change, and physician recommendation moderated the intervention effects.

CONCLUSIONS

A tailored intervention was not more effective at increasing screening than a public web site or only being surveyed.

Patient-rated importance and receipt of information for colorectal cancer screening

BACKGROUND

Physician recommendation is one of the most important determinants of obtaining colorectal cancer (CRC) screening; however, little is known about the degree to which CRC screening discussions include information that patients report as important to guide screening decisions. This study examines and compares both patient rated importance and physician communication of key information elements about CRC screening during annual physical examinations.

METHODS

DESIGN

Cross-sectional cohort.

SETTING

26 ambulatory clinics of an integrated delivery system in the Midwest.

PARTICIPANTS

64 primary care physicians and 415 patients aged 50 to 80 due for CRC screening. Patients completed a previsit survey to assess importance of specific information when making a preventive screening decision. Visits were audio recorded to assess the content of screening discussions.

RESULTS

Most patients rated test accuracy (85%), testing alternatives (83%), the pros and cons of testing (86%), and the testing process (78%) very important when making preventive screening decisions. Ninety-one percent of visits included a CRC screening discussion; however, CRC screening talk rarely included information that patients rated as important. Physicians infrequently asked whether patients had questions pertaining to CRC screening (5%); however, 49% of patients asked a CRC screening question, with the vast majority pertaining to screening logistics.

CONCLUSIONS

Audio recordings confirm that discussions of CRC screening are often lacking information that patients indicate is very important when making preventive health decisions and patient questions during the visit are not eliciting information to fill the gap.

IMPACT

These findings provide actionable information to improve CRC screening discussions.

Physicians' colorectal cancer screening discussion and recommendation patterns

BACKGROUND

Primary care physician (PCP) actions are pivotal to colorectal cancer (CRC) screening performance, and guidelines recommend discussion with patients about test options and potential benefits and harms. This article profiles patterns of discussion about and recommendations for screening and explores potential associations with multilevel factors (patient, clinician, practice, and environment).

METHODS

In 2009, we analyzed data from 1,266 physicians responding to the 2006-2007 National Survey of Primary Care Physicians' Recommendations and Practices for Breast, Cervical, Colorectal, and Lung Cancer Screening (absolute response rate=69.3%; cooperation rate=75.0%). Descriptive statistics examined physicians' reports of discussion and recommendations. Multivariate analyses assessed the associations of these practices with multilevel factors.

RESULTS

Although few respondents reported discussion of all options, 46% usually discuss more than one option; the vast majority of these respondents discuss fecal occult blood testing (FOBT) and colonoscopy (49%) or FOBT, sigmoidoscopy, and colonoscopy (32%). Of physicians who discuss more than one option, a majority reported usually recommending one or more test options, most commonly colonoscopy alone (43%) and FOBT and colonoscopy (43%). Several personal characteristics (specialty), perceived patient characteristics (prefer physician to decide), practice characteristics (geographic location), and community barriers (specialist availability) were independently associated with discussion and/or recommendation patterns.

CONCLUSIONS

PCPs do not discuss the full menu of test options, but many report selecting one or two options for discussion and recommendation. To ensure that patients' perspectives and concerns are elicited and considered, patient decision-making approaches should be considered.

IMPACT

Attention to informed decision making in CRC screening will be important for enhancing patient-centered quality care.

Barriers to colorectal cancer screening: physician and general population perspectives, New Mexico, 2006

INTRODUCTION

Colorectal cancer (CRC) screening rates are low in New Mexico. We used statewide surveys of primary care physicians and the general population to characterize CRC screening practices and compare perceptions about screening barriers.

METHODS

In 2006, we surveyed 714 primary care physicians in New Mexico about their CRC screening practices, beliefs, and perceptions of patient, provider, and system barriers. A 2004 state-specific CRC screening module for the Behavioral Risk Factor Surveillance System (BRFSS) survey asked 3,355 participants aged 50 years or older why they had not ever or had not recently completed a fecal occult blood test (FOBT) or lower endoscopy.

RESULTS

The 216 physicians (30% response rate) reported offering screening to a median 80% of their average-risk patients in the past year and estimated that a median 50% were current with screening. They attributed low screening proportions mainly to patient factors (embarrassment, fear of pain, lack of insurance). However, just 51% of physician respondents used health maintenance flow sheets, and only 13% used electronic medical records to identify patients due for CRC screening. The BRFSS respondents most often reported that lack of physician discussion was responsible for not being current with screening (45% FOBT, 34% endoscopy); being asymptomatic was also often cited as an explanation for lack of screening (22% FOBT, 36% endoscopy).

CONCLUSION

Physicians and adults in the general population had markedly different perspectives on barriers to CRC screening. Increasing screening may require system supports to help physicians readily identify patients due for CRC testing and interventions to educate patients about the rationale for screening.

The impact of a novel computer-based decision aid on shared decision making for colorectal cancer screening: a randomized trial

BACKGROUND

Eliciting patients' preferences within a framework of shared decision making (SDM) has been advocated as a strategy for increasing colorectal cancer (CRC) screening adherence. Our objective was to assess the effectiveness of a novel decision aid on SDM in the primary care setting.

METHODS

An interactive, computer-based decision aid for CRC screening was developed and evaluated within the context of a randomized controlled trial. A total of 665 average-risk patients (mean age, 57 years; 60% female; 63% black, 6% Hispanic) were allocated to 1 of 2 intervention arms (decision aid alone, decision aid plus personalized risk assessment) or a control arm. The interventions were delivered just prior to a scheduled primary care visit. Outcome measures (patient preferences, knowledge, satisfaction with the decision-making process [SDMP], concordance between patient preference and test ordered, and intentions) were evaluated using prestudy/poststudy visit questionnaires and electronic scheduling.

RESULTS

Overall, 95% of patients in the intervention arms identified a preferred screening option based on values placed on individual test features. Mean cumulative knowledge, SDMP, and intention scores were significantly higher for both intervention groups compared with the control group. Concordance between patient preference and test ordered was 59%. Patients who preferred colonoscopy were more likely to have a test ordered than those who preferred an alternative option (83% v. 70%; P < 0.01). Intention scores were significantly higher when the test ordered reflected patient preferences.

CONCLUSIONS

Our interactive computer-based decision aid facilitates SDM, but overall effectiveness is determined by the extent to which providers comply with patient preferences.

Community involvement in the development and feedback about a colorectal cancer screening media campaign in Ohio Appalachia

A community needs assessment focused on colorectal cancer (CRC) screening knowledge, behaviors, and barriers was completed in one Ohio Appalachia county. A CRC screening media campaign was developed based on the findings from the needs assessment and feedback was obtained about the media campaign. The survey was completed by 170 self-reported average-risk adults. In a multivariate model, the CRC screening rate was higher for participants who had received a doctor's recommendation (OR = 6.09) and had adequate CRC knowledge (OR = 2.88), and it was lower among participants employed full-time (OR = 0.23). Having health insurance (OR = 4.20) and being married (OR = 2.58) was associated with having received a doctor's recommendation for screening. Campaign feedback using a second survey completed by self-reported average-risk adults (n = 61) revealed that 69% recognized the campaign image and message, with a billboard being the most cited source. This study highlights the importance of involving community members in the development of CRC screening programs to reduce cancer disparities in Appalachia.

Is discussion of colorectal cancer screening options associated with heightened patient confusion?

BACKGROUND

Clinical guidelines recommend offering patients options for colorectal cancer (CRC) screening, but the modalities vary by frequency, accuracy, preparations, discomfort, and cost, which may cause confusion and reduce screening rates. We examined whether patients reported confusion about the options and whether confusion was associated with socio-demographic characteristics, number of options discussed, and adherence.

METHODS

Patients ages 50 to 75 years who had visited a clinician within 2 years were randomly selected for a cross-sectional study (n = 6,100). A questionnaire mailed in 2007 asked the following: whether a clinician had ever discussed CRC screening options; which of four recommended tests (i.e., fecal occult blood testing, flexible sigmoidoscopy, colonoscopy, and barium enema) were presented; and whether the options were confusing. Analyses were restricted to respondents who reported discussing one or more screening options (n = 1,707). Weighted frequencies were calculated and multivariate logistic regression was done.

RESULTS

The sample was 55.5% female, 15.6% African American, and 83.2% adherent to screening recommendations, and 56.0% had discussed two or more screening options. In adjusted analyses, nonadherent patients reported greater confusion than adherent patients (P < 0.01). Adults who discussed two or more options were 1.6 times more likely to be confused than those who discussed one option [95% confidence interval (CI), 1.08-2.26]. Patients who reported being confused were 1.8 times more likely to be nonadherent to screening than those who did not (95% CI, 1.14-2.75).

CONCLUSIONS

Our study provides the first empirical evidence linking multiple options with confusion and confusion with screening adherence.

IMPACT

Confusion may act as a barrier to screening and should be considered in public health messages and interventions.

Is discussion of colorectal cancer screening options associated with heightened patient confusion?

BACKGROUND

Clinical guidelines recommend offering patients options for colorectal cancer (CRC) screening, but the modalities vary by frequency, accuracy, preparations, discomfort, and cost, which may cause confusion and reduce screening rates. We examined whether patients reported confusion about the options and whether confusion was associated with socio-demographic characteristics, number of options discussed, and adherence.

METHODS

Patients ages 50 to 75 years who had visited a clinician within 2 years were randomly selected for a cross-sectional study (n = 6,100). A questionnaire mailed in 2007 asked the following: whether a clinician had ever discussed CRC screening options; which of four recommended tests (i.e., fecal occult blood testing, flexible sigmoidoscopy, colonoscopy, and barium enema) were presented; and whether the options were confusing. Analyses were restricted to respondents who reported discussing one or more screening options (n = 1,707). Weighted frequencies were calculated and multivariate logistic regression was done.

RESULTS

The sample was 55.5% female, 15.6% African American, and 83.2% adherent to screening recommendations, and 56.0% had discussed two or more screening options. In adjusted analyses, nonadherent patients reported greater confusion than adherent patients (P < 0.01). Adults who discussed two or more options were 1.6 times more likely to be confused than those who discussed one option [95% confidence interval (CI), 1.08-2.26]. Patients who reported being confused were 1.8 times more likely to be nonadherent to screening than those who did not (95% CI, 1.14-2.75).

CONCLUSIONS

Our study provides the first empirical evidence linking multiple options with confusion and confusion with screening adherence.

IMPACT

Confusion may act as a barrier to screening and should be considered in public health messages and interventions.

A targeted decision aid for the elderly to decide whether to undergo colorectal cancer screening: development and results of an uncontrolled trial

BACKGROUND

Competing causes of mortality in the elderly decrease the potential net benefit from colorectal cancer screening and increase the likelihood of potential harms. Individualized decision making has been recommended, so that the elderly can decide whether or not to undergo colorectal cancer (CRC) screening. The objective is to develop and test a decision aid designed to promote individualized colorectal cancer screening decision making for adults age 75 and over.

METHODS

We used formative research and cognitive testing to develop and refine the decision aid. We then tested the decision aid in an uncontrolled trial. The primary outcome was the proportion of patients who were prepared to make an individualized decision, defined a priori as having adequate knowledge (10/15 questions correct) and clear values (25 or less on values clarity subscale of decisional conflict scale). Secondary outcomes included overall score on the decisional conflict scale, and preferences for undergoing screening.

RESULTS

We enrolled 46 adults in the trial. The decision aid increased the proportion of participants with adequate knowledge from 4% to 52% (p < 0.01) and the proportion prepared to make an individualized decision from 4% to 41% (p < 0.01). The proportion that preferred to undergo CRC screening decreased from 67% to 61% (p = 0. 76); 7 participants (15%) changed screening preference (5 against screening, 2 in favor of screening)

CONCLUSION

In an uncontrolled trial, the elderly participants appeared better prepared to make an individualized decision about whether or not to undergo CRC screening after using the decision aid.

Decision-making processes for breast, colorectal, and prostate cancer screening: the DECISIONS survey

BACKGROUND

Patients should understand the risks and benefits of cancer screening in order to make informed screening decisions.

OBJECTIVES

To evaluate the extent of informed decision making in patient-provider discussions for colorectal (CRC), breast (BrCa), and prostate (PCa) cancer screening.

SETTING

National sample of US adults identified by random-digit dialing.

DESIGN

Cross-sectional survey conducted between November 2006 and May 2007.

PARTICIPANTS

English-speaking US adults aged 50 y and older who had discussed cancer screening with a health care provider within the previous 2 y.

MEASUREMENTS

Cancer screening survey modules that asked about demographic characteristics, cancer knowledge, the importance of various sources of information, and self-reported cancer screening decision-making processes.

RESULTS

Overall, 1082 participants completed 1 or more of the 3 cancer modules. Although participants generally considered themselves well informed about screening tests, half or more could not correctly answer even 1 open-ended knowledge question for any given module. Participants consistently overestimated risks for being diagnosed with and dying from each cancer and overestimated the positive predictive values of prostate-specific antigen tests and mammography. Providers were the most highly rated information source, usually initiated screening discussions (64%-84%), and often recommended screening (73%-90%). However, participants reported that providers elicited their screening preferences in only 31% (CRC women) to 57% (PCa) of discussions. Although more than 90% of the discussions addressed the pros of screening, only 19% (BrCa) to 30% (PCa) addressed the cons of screening.

LIMITATIONS

Recall bias is possible because screening process reports were not independently validated.

CONCLUSIONS

Cancer screening decisions reported by patients who discussed screening with their health care providers consistently failed to meet criteria for being informed. Given the high ratings for provider information and frequent recommendations for screening, providers have important opportunities to ensure that informed decision making occurs for cancer screening decisions.

Race/ethnicity, quality of care, and outcomes in ischemic stroke

BACKGROUND

Prior studies suggest differences in stroke care associated with race/ethnicity. We sought to determine whether such differences existed in a population of black, Hispanic, and white patients hospitalized with stroke among hospitals participating in a quality-improvement program.

METHODS AND RESULTS

We analyzed in-hospital mortality and 7 stroke performance measures among 397,257 patients admitted with ischemic stroke to 1181 hospitals participating in the Get With The Guidelines-Stroke program 2003 through 2008. Relative to white patients, black and Hispanic patients were younger and more often had diabetes mellitus and hypertension. After adjustment for both patient- and hospital-level variables, black patients had lower odds relative to white patients of receiving intravenous thrombolysis (odds ratio [OR], 0.84; 95% confidence interval [CI], 0.77 to 0.91), deep vein thrombosis prophylaxis (OR, 0.88; 95% CI, 0.83 to 0.92), smoking cessation (OR, 0.85; 95% CI, 0.79 to 0.91), discharge antithrombotics (OR, 0.88; 95% CI, 0.84 to 0.92), anticoagulants for atrial fibrillation (OR, 0.84; 95% CI, 0.75 to 0.94), and lipid therapy (OR, 0.91; 95% CI, 0.88 to 0.96), and of dying in-hospital (OR, 0.90; 95% CI, 0.85 to 0.95). Hispanic patients received similar care as their white counterparts on all 7 measures and had similar in-hospital mortality. Black (OR, 1.31; 95% CI, 1.28 to 1.35) and Hispanic (OR, 1.16; 95% CI, 1.11 to 1.20) patients had higher odds of exceeding the median length of hospital stay relative to whites. During the study, quality of care improved in all 3 race/ethnicity groups.

CONCLUSIONS

Black patients with stroke received fewer evidence-based care processes than Hispanic or white patients. These differences could lead to increased risk of recurrent stroke. Quality of care improved substantially in the Get With The Guidelines-Stroke Program over time for all 3 racial/ethnic groups.

Patient numeracy, perceptions of provider communication, and colorectal cancer screening utilization

Patients with poor numeracy skills may have difficulty participating in shared-decision making, affecting their utilization of colorectal cancer (CRC) screening. We explored the relationship between numeracy, provider communication, and CRC screening. Data were from the 2007 National Cancer Institute Health Information Trends Survey. Individuals age 50 years or older responded via mail or phone to items measuring numeracy, perceptions of provider communication quality, and CRC screening. After accounting for national sampling weights, multivariate logistic regression models examined the association between these factors. A total of 1,436 subjects responded to an objective numeracy item via mail, and 3,286 responded to a subjective numeracy item via mail or phone; 22.6% had low objective numeracy, and 39.4% had low subjective numeracy. Low subjective numeracy was associated with a lower likelihood of perceiving high quality provider communication (OR 0.63-0.73), but for low objective numeracy, the opposite was observed (OR 1.51-1.64). Low objective or subjective numeracy was associated with less CRC screening. There was significant interaction between subjective numeracy, perceptions of provider communication, and CRC screening. Patient numeracy is associated with perceptions of provider communication quality. For individuals with low subjective numeracy, perceiving high quality communication offset the association between low numeracy and underutilization of CRC screening.

Behind closed doors: physician-patient discussions about colorectal cancer screening

BACKGROUND

Despite the availability of multiple effective screening tests for colorectal cancer, screening rates remain suboptimal. The literature documents patient preferences for different test types and recommends a shared decision-making approach for physician-patient colorectal cancer screening (CRCS) discussions, but it is unknown whether such communication about CRCS preferences and options actually occurs in busy primary-care settings.

OBJECTIVE

Describe physician-patient CRCS discussions during a wellness visit.

DESIGN

Cross-sectional; patients audio-recorded with physicians.

PARTICIPANTS

A subset of patients (N = 64) participating in a behavioral intervention trial designed to increase CRCS who completed a wellness visit during the trial with a participating physician (N = 8).

APPROACH

Transcripts were analyzed using qualitative methods.

RESULTS

Physicians in this sample consistently recommended CRCS, but focused on colonoscopy. Physicians did not offer a fecal occult blood test alone as a screening choice, which may have created missed opportunities for some patients to get screened. In this single visit, physicians' communication processes generally precluded discussion of patients' test preferences and did not facilitate shared decision-making. Patients' questions indicated their interest in different CRCS test types and appeared to elicit more information from physicians. Some patients remained resistant to CRCS after discussing it with a physician.

CONCLUSION

If a preference for colonoscopy is widespread among primary-care physicians, the implications for intervention are either to prepare patients for this preference or to train physicians to offer options when recommending screening to patients.

Factors influencing choices for colorectal cancer screening among previously unscreened African and Caucasian Americans: findings from a triangulation mixed methods investigation

We investigated factors that influence choice of colorectal cancer (CRC) screening test and assessed the most- and least-preferred options among fecal occult blood testing (FOBT), flexible sigmoidoscopy, colonoscopy, and double contrast barium enema among adults with varied race, gender, and geographic region demographics. Mixed methods data collection consisted of 10 focus group interviews and a survey of the 93 focus group participants. Participants were >or=50 years of age and reported not having been screened for colorectal cancer in the last ten years. Analyses examined differences by race, gender, and geographic location. Participants had modest knowledge about CRC and there were fewer correct answers to knowledge questions by African Americans. Participants recognized value of early detection, and identified health symptoms and their doctor's recommendation as influential for obtaining CRC screening. They chose colonoscopy and FOBT as the most preferred tests, while barium enema was least preferred. The analysis revealed intra-group variations in preference, though there were no significant differences by race, gender, or location. Openness of discussing this sensitive topic, lack of knowledge about colorectal cancer and screening costs, and diversity of preferences expressed within study groups suggest the importance of patient-physician dialogue about colorectal cancer screening options. New approaches to promoting colorectal cancer screening need to explore methods to facilitate patients establishing and expressing preferences among the screening options.

Promoting informed decision-making in a primary care practice by implementing decision aids

Empowering patients to be effective advocates for their health requires that they have adequate information and understanding about their health conditions. Many patients have limited health literacy which is a marker for vulnerability and a risk factor for poor health outcomes. Providing vulnerable patients with information in a format they can easily access is challenging. One novel approach is to modify processes of clinical care so that medical practices deliver necessary and accessible information to patients in conjunction with their provider’s visit. The goal is to improve the quality of medical care in clinical practice by promoting informed decision-making.