Patient trust in physician influences colorectal cancer screening in low-income patients

Colorectal Cancer Screening Rates at Federally Qualified Health Centers From 2014 to 2022: Incomplete Recovery From COVID-19 and Worsening Disparities

INTRODUCTION

Federally Qualified Health Centers (FQHC) provide preventive health services such as colorectal cancer (CRC) screening to low-income and underinsured individuals. Overall CRC screening participation in the United States declined during the COVID-19 pandemic and recovered by 2021; however, trends in underresourced settings are unknown.

METHODS

Using Uniform Data System data from 2014 to 2022, we assessed trends in FQHC CRC screening rates nationally, in California, and in Los Angeles County and determined clinic-level factors associated with recent screening rate changes. For each FQHC, we calculated the screening rate change from 2019 to 2020, 2020 to 2021, and 2020 to 2022. We used mixed-effects linear regression to determine clinic-level characteristics associated with each screening rate change.

RESULTS

Across all FQHC (n = 1,281), 7,016,181 patients were eligible for CRC screening in 2022. Across the United States and in California, median screening rates increased from 2014 to 2019, severely declined in 2020, and failed to return to prepandemic levels by 2022. Both nationally and in California, CRC screening declined most dramatically from 2019 to 2020 in FQHC serving majority Hispanic/Latino patients or a high proportion of patients experiencing homelessness. From 2020 to 2022, screening rates did not recover completely in US FQHC, with disproportionate recovery among FQHC serving majority non-Hispanic Black patients.

DISCUSSION

CRC screening rates at FQHC did not return to prepandemic levels by 2022, and recovery varied by FQHC patient characteristics. Tailored interventions addressing low and decreasing CRC screening rates in FQHC are urgently needed to mitigate worsening CRC disparities.

Income differences in time to colon cancer diagnosis

INTRODUCTION

People with low income have worse outcomes throughout the cancer care continuum; however, little is known about income and the diagnostic interval. We described diagnostic pathways by neighborhood income and investigated the association between income and the diagnostic interval.

METHODS

This was a retrospective cohort study of colon cancer patients diagnosed 2007-2019 in Ontario using routinely collected data. The diagnostic interval was defined as the number of days from the first colon cancer encounter to diagnosis. Asymptomatic pathways were defined as first encounter with a colonoscopy or guaiac fecal occult blood test not occurring in the emergency department and were examined separately from symptomatic pathways. Quantile regression was used to determine the association between neighborhood income quintile and the conditional 50th and 90th percentile diagnostic interval controlling for age, sex, rural residence, and year of diagnosis.

RESULTS

A total of 64,303 colon cancer patients were included. Patients residing in the lowest income neighborhoods were more likely to be diagnosed through symptomatic pathways and in the emergency department. Living in low-income neighborhoods was associated with longer 50th and 90th-percentile symptomatic diagnostic intervals compared to patients living in the highest income neighborhoods. For example, the 90th percentile diagnostic interval was 15 days (95% CI 6-23) longer in patients living in the lowest income neighborhoods compared to the highest.

CONCLUSION

These findings reveal income inequities during the diagnostic phase of colon cancer. Future work should determine pathways to reducing inequalities along the diagnostic interval and evaluate screening and diagnostic assessment programs from an equity perspective.

Trends in and factors associated with family physician-performed screening colonoscopies in the United States: 2016-2021

PURPOSE

Family physician (FP)-performed screening colonoscopies can serve as 1 strategy in the multifaceted strategy necessary to improve national colorectal cancer screening rates, particularly in rural areas where specialist models can fail. However, little research exists on the performance of this strategy in the real world. In this study, we evaluated trends in and factors associated with FP-performed screening colonoscopies in the United States between 2016 and 2021.

METHODS

Using national data from Merative's Marketscan insurance claims database, we estimate the proportion of screening colonoscopies performed by FPs. We use logistic regression models to evaluate factors independently associated with FP-performed colonoscopies.

RESULTS

The percentage of screening colonoscopies performed by FPs exhibited a downward trend from 11.32% in 2016 to 6.73% in 2021, with the largest decrease occurring among patients from the most rural areas. FPs were more likely to perform colonoscopies on slightly older patients, male patients, and rural patients. Patients were less likely to receive FP-performed colonoscopies in large metropolitan areas compared to lesser populated areas. Patients were more likely to receive FP-performed colonoscopies in the Midwest, South, and West, even after accounting for urban-rural classification.

CONCLUSION

Despite a downward trajectory, FPs perform a substantial proportion of screening colonoscopies in the United States. Changes to the business side of health care delivery may be contributing to the observed decreasing rate. Whether through spatial or relational proximity, FPs may be better positioned to provide colonoscopy to some rural, male, and older patients who otherwise may not have been screened. Policy changes to expand the FP workforce, particularly in rural areas, are likely necessary to slow or reverse the downward trend of FP-performed screening colonoscopies.

Age as a Moderator of Health Outcomes and Trust in Physicians

Objectives: Patient trust in physicians is associated with patient satisfaction with healthcare, patients engaging in follow-up care, and positive health-related outcomes. The current study investigated whether age moderated the relation between trust in physicians and four health outcome variables, including patient satisfaction, doctor visits, emergency room visits, and hospital admissions. Methods: 398 English-speaking, community-dwelling adults completed measures of physician trust and important health outcome variables via Amazon Mechanical Turk. Results: Age significantly moderated relations between trust in physicians and hospital admissions, and trust in physicians and patient satisfaction, with both positive relations becoming stronger with increasing age. Discussion: The results highlight the need for a lifespan approach to the study of physician trust and related health outcomes. They offer an avenue for increasing physician trust, engagement with the healthcare system prior to the need for hospitalization, and the reduction of healthcare costs.

Screening, awareness and challenges for colorectal cancer treatment in Saudi Arabia: an update

Colorectal cancer (CRC) is the second most common cancer in the world. In Saudi Arabia, CRC is the most common cancer in males and the third most common in females, and its incidence rate is rising as the country continues to develop. However, the country does not have a national CRC screening program for CRC. This review aims to review recent studies that have attempted to address and rectify this issue and discern the most notable and prevalent barriers. Despite these efforts, guidelines are still lacking. Two prospective studies have been conducted in recent years, one of which was a national pilot screening program conducted by the Ministry of Health (MOH). While both had a similar number of participants, the colonoscopy rate for patients with a positive fecal immunochemical test (FIT) in the MOH program was only 20% compared to 75.8% in the Al-Kharj program. Awareness of the Saudi population regarding CRC and its screening appears to be insufficient. The most common barriers to patients' willingness to undergo screening were embarrassment, fear, and pain. Barriers to physicians are mostly related to factors outside their hands, such as lack of equipment and time. We conclude that efforts should be made to establish a national screening program and improve awareness of the population and physicians.

Colorectal Cancer Screening After Sequential Outreach Components in a Demographically Diverse Cohort

Importance

Organized screening outreach can reduce differences in colorectal cancer (CRC) incidence and mortality between demographic subgroups. Outcomes associated with additional outreach, beyond universal outreach, are not well known.

Objective

To compare CRC screening completion by race and ethnicity, age, and sex after universal automated outreach and additional personalized outreach.

Design, Setting, and Participants

This observational cohort study included screening-eligible individuals aged 50 to 75 years assessed during 2019 in a community-based organized CRC screening program within the Kaiser Permanente Northern California (KPNC) integrated health care delivery setting. For KPNC members who are not up to date with screening by colonoscopy, each year the program first uses automated outreach (mailed prescreening notification postcards and fecal immunochemical test [FIT] kits, automated telephone calls, and postcard reminders), followed by personalized components for nonresponders (telephone calls, electronic messaging, and screening offers during office visits). Data analyses were performed between November 2021 and February 2023 and completed on February 5, 2023.

Exposures

Completed CRC screening via colonoscopy, sigmoidoscopy, or FIT.

Main Outcomes and Measures

The primary outcome was the proportion of participants completing an FIT or colonoscopy after each component of the screening process. Differences across subgroups were assessed using the χ2 test.

Results

This study included 1 046 745 KPNC members. Their mean (SD) age was 61.1 (6.9) years, and more than half (53.2%) were women. A total of 0.4% of members were American Indian or Alaska Native, 18.5% were Asian, 7.2% were Black, 16.2% were Hispanic, 0.8% were Native Hawaiian or Other Pacific Islander, and 56.5% were White. Automated outreach significantly increased screening participation by 31.1%, 38.1%, 29.5%, 31.9%, 31.8%, and 34.5% among these groups, respectively; follow-up personalized outreach further significantly increased participation by absolute additional increases of 12.5%, 12.4%, 13.3%, 14.4%, 14.7%, and 11.2%, respectively (all differences P < .05 compared with White members). Overall screening coverage at the end of the yearly program differed significantly among members who were American Indian or Alaska Native (74.1%), Asian (83.5%), Black (77.7%), Hispanic (76.4%), or Native Hawaiian or Other Pacific Islander (74.4%) compared with White members (82.2%) (all differences P < .05 compared with White members). Screening completion was similar by sex; older members were substantially more likely to be up to date with CRC screening both before and at the end of the screening process.

Conclusions and Relevance

In this cohort study of a CRC screening program, sequential automated and personalized strategies each contributed to substantial increases in screening completion in all demographic groups. These findings suggest that such programs may potentially reduce differences in CRC screening completion across demographic groups.

Bounded rationality in healthcare: unraveling the psychological factors behind patient satisfaction in China

Introduction

Patient satisfaction is a crucial metric to gauge the quality of medical services, but the psychological factors influencing patient satisfaction remain insufficiently explored.

Methods

This study examines these psychological factors by applying the theory of bounded rationality to 1,442 inpatients in Hangzhou, China, whose data were collected using a questionnaire. One-way ANOVA, correlation analysis, and hierarchical regression were used to analyze patient satisfaction and its associated factors. Additionally, the path analysis of the structural equation model revealed the mechanisms behind the key psychological factors that influenced patient satisfaction.

Results

Medical risk perception, the social cognition of the medical environment, and social desirability bias had significant positive impacts on patient satisfaction. By contrast, negative emotions had a significant negative impact on patient satisfaction. Notably, patients' negative emotions had both a suppressive effect and a positive moderating effect on the relationship between medical risk perception and patient satisfaction. Similarly, social desirability bias had a suppressive effect on the correlation between the social cognition of the medical environment and patient satisfaction, albeit with a negative moderating effect.

Discussion

These results suggest that when evaluating and improving patient satisfaction, accounting only for the factors that directly influence medical service quality is insufficient, as the indirect and moderating effects of patients' negative emotions and the social cognition of the medical environment must also be considered. Medical service providers should thus address patients' negative emotions, establish good doctor-patient relationships, optimize service environments, provide managers with medical risk education and training on negative emotions, and prioritize patient-centered care. Additionally, the government and relevant health departments should optimize medical policies, enhance fairness and accessibility, and create a positive social cognitive environment through public education and awareness campaigns.

Patient Decisions Regarding Rescheduling Colonoscopies Postponed Due to the COVID-19 Pandemic

BACKGROUND

Due to the COVID-19 pandemic, elective colonoscopies were postponed in Ohio from 3/17/2020 to 5/1/2020. When the ban was lifted, canceled patients determined whether to reschedule their colonoscopy in the midst of the ongoing pandemic.

AIMS

We aim to determine whether demographic, colorectal cancer (CRC) risk, and COVID-19 morbidity and mortality risk factors are associated with rescheduling of colonoscopies canceled by the COVID-19 pandemic.

METHODS

A medical record review of 420 participants ages 40-74 at a midwestern academic health system with elective colonoscopies canceled from 3/17/2020 to 5/1/2020 due to the COVID-19 pandemic was performed.

RESULTS

More than half of participants (71.0%) rescheduled their colonoscopy within the next 8 months. Indication for colonoscopy being 'surveillance following adenoma', colonoscopy ordered by primary care provider rather than gastroenterologist, and dyslipidemia were independently associated with rescheduling colonoscopy. Higher body mass index, indication for colonoscopy being simply 'screening for CRC,' and stool testing were associated with not rescheduling. Diagnoses associated with colorectal cancer risk such as adenomas, personal or family history of colorectal cancer, and inflammatory bowel disease were not associated with rescheduling, nor were other comorbidities associated with increased COVID-19 severity. 4.5% (19/420) opted for stool fecal immunochemical test or Cologuard testing.

CONCLUSIONS

Most patients rescheduled their colonoscopy despite the risk of virus exposure, suggesting that concern of missed colorectal cancer diagnosis outweighed coronavirus concerns. Patient trust in referring providers may be important for rescheduling, and colonoscopy indications were independently associated with rescheduling status.

The Association between Levels of Trust in the Healthcare System and Influenza Vaccine Hesitancy among College Students in Israel

Influenza is a contagious respiratory disease caused by the influenza virus. Vaccination proves an effective approach to preventing influenza and minimizing the risk of experiencing associated complications. However, the influenza vaccine coverage rate among Israeli college students is low due to a sense of complacency, lack of knowledge, and vaccine hesitancy. The current study examined the relationship between the level of trust in the healthcare system and influenza vaccine hesitancy among college students in Israel. This cross-sectional study was conducted via an online questionnaire in April-May 2023. In total, 610 students were surveyed, of whom 57% had been vaccinated against influenza in the past; however, only 12% were vaccinated this year. Negative, significant, and moderate relationships were found between the level of trust in the healthcare system and influenza vaccine hesitancy. Students who had been vaccinated in the past had a higher level of trust in the healthcare system and a lower level of vaccination hesitancy. The linear regression model revealed that the variables of being a woman, not Jewish, vaccinated, and trusting the Ministry of Health, family doctor, and health professionals were associated with a decrease in vaccine hesitancy. These findings are in line with previous research in the field. Based on the present results, it may be advisable to develop intervention programs aimed at increasing confidence in the healthcare system and vaccinations by providing knowledge and addressing students' concerns regarding vaccination.

Colorectal Cancer (CRC) Screening Literacy and Facilitators Related to a Free Screening Program in Thailand

OBJECTIVE

This study aimed to evaluate CRC screening literacy and to determine the association between demographic characteristics and levels of CRC screening literacy and facilitators motivating participation.

METHODS

This cross-sectional study was carried out with 1,272 Thai citizens aged 50-70 years consenting to complete the screening protocol. Data were collected at the final visit by a self-reported questionnaire which was developed and validated using I-CVI=1. Difficulty of CRC screening knowledge dimension was tested by KR20, Cronbach's alpha 0.49.

RESULTS

The majority of participants, 834 (65.6%) had sufficient CRC screening literacy and association between characteristics and levels of CRC screening literacy was not different. Comparing between characteristics and facilitators showed significant differences in trusting healthcare providers, perceiving harmless procedures, having constipation and time available. By married and own income participants exhibited lower trust in healthcare providers, 68% (OR 0.32, 95%CI 0.14 - 0.73) and 59% (OR 0.41, 95%CI 0.19 - 0.95), respectively. Married individuals perceived the procedures of screening involved higher harm, 32% (OR 0.68, 95%CI 0.45 - 0.99). Female and age over 60 with constipation constituted higher screening, 1.9 fold (OR 1.93, 95%CI 1.44 - 2.60) and 1.4 fold (OR 1.44, 95%CI 1.09 - 1.90). Though time available, age over 60 was lower screening 56% (OR 0.44, 95%CI 0.24 - 0.80), while own income and income more than 30,000 THB/month participants constituted higher screening 15 fold (OR 15.14, 95%CI 4.72 - 48.56) and 2.5 fold (OR 2.50, 95%CI 1.50 - 4.18), respectively.

CONCLUSION

CRC screening literacy of participants was high. The association between characteristics and CRC screening literacy levels did not differ while characteristics and facilitators differed in some aspects. The free program promoted CRC screening equity; however, multilevel facilitators must be concerned, prioritized and intervened to motivate participation.

Patient and Provider Perceptions About Communication After Bariatric Surgery: A Qualitative Analysis

INTRODUCTION

Communication between patients and providers can strongly influence patient behavior after surgery. The objective of this study was to assess patient and provider perceptions of how communication affected weight-related behaviors after bariatric surgery.

MATERIALS AND METHODS

Semistructured interviews with bariatric surgery patients and providers were conducted from April-November 2020. Patients who had Medicaid within 3 y of surgery were defined as socioeconomically disadvantaged. Interview guides were derived from Andersen's Behavioral Model of Health Services and Torain's Framework for Surgical Disparities. Participants described postoperative experiences regarding diet, physical activity, and follow-up care. A codebook was developed deductively based on the two theories. Directed content analysis identified themes pertaining to patient-provider communication.

RESULTS

Forty-five participants were interviewed, including 24 patients (83% female; 79% White), six primary care providers, four health psychologists, five registered dietitians, and six bariatric surgeons. Four themes regarding communication emerged: (1) Patients experiencing weight regain did not want to follow-up with providers to discuss their weight; (2) Patients from socioeconomically disadvantaged backgrounds had less trust and required more rapport-building from providers to enhance trust; (3) Patients felt that providers did not get to know them personally, which was perceived as a lack of personalized communication; and (4) Providers often changed their language to be simpler, so patients could understand them.

CONCLUSIONS

Patient-provider communication after bariatric surgery is essential, but perceptions about the elements of communication differ between patients and providers. Reassuring patients who have attained less weight loss than expected and establishing trust with socioeconomically vulnerable patients could strengthen care after bariatric surgery.

Recognising socio-cultural barriers while seeking early detection services for breast cancer: a study from a Universal Health Coverage setting in India

BACKGROUND

Breast cancer is the commonest cancer among women in India, yet the uptake of early detection programs is poor. This leads to late presentation, advanced stage at the time of diagnosis, and high mortality. Poor accessibility and affordability are the most commonly cited barriers to screening: we analyse socio-cultural factors influencing the uptake of early detection programmes in a Universal Health Coverage (UHC) setting in India, where geographical and financial barriers were mitigated.

METHODS

Two hundred seventy-two women engaging in an awareness-based early detection program were recruited by randomization as the participant (P) group. A further 272 women who did not participate in the early detection programme were recruited as non-participants (NP). None of the groups were previously screened for breast cancer. Interviews were conducted using a 19-point questionnaire, consisting of closed-ended questions regarding demographics and social, cultural, spiritual and trust-related barriers.

RESULTS

The overall awareness about breast cancer was high among both groups. None of the groups reported accessibility-related barriers. Participants were more educated (58.09% vs 47.43%, p = 0.02) and belonged to nuclear families (83.59% vs 76.75%, p = 0.05). Although they reported more fear of isolation due to stigma (25% vs 14%, p = 0.001), they had greater knowledge about breast cancer and trust in the health system compared to non-participants.

CONCLUSIONS

The major socio-cultural barriers identified were joint family setups, lower education and awareness, and lack of trust in healthcare professionals. As more countries progress towards UHC, recognising socio-cultural barriers to seeking breast health services is essential in order to formulate context-specific solutions to increase the uptake of early detection and screening services.

Measuring Trust in Primary Care

Policy Points Trust in primary care clinicians is essential for effective patient care and is associated with better health outcomes, but it is rarely assessed, and existing measures have not been thoroughly evaluated. This scoping review reveals that research assessing patients' trust in primary care clinicians largely stopped more than a decade ago but offers candidate measures for future testing, implementation, and policy applications.

CONTEXT

Trust is a fundamental aspect of any human relationship, and medical care is no exception. An ongoing, trusting relationship between clinicians and patients has shown demonstrable value to primary care. However, there is currently no measure of trust in general use, and none endorsed for use by most value-based payment programs. This review searched the literature for any existing measures of patient trust in primary care clinicians and assessed their potential to be implemented as a patient-reported outcome measure.

METHODS

A keyword search on PubMed along with scanning references was conducted to find any trust measures in health care. Measures that did not address primary care clinicians were eliminated and the remaining measures were then assessed for their utility to primary care.

RESULTS

This purposeful, scoping review found four tested measures for assessing patients' trust in primary care clinicians that are candidates for general use. Of these four, the revised Trust in Physicians Scale and Wake Forest Physician Trust Scale are the most tested and viable options.

CONCLUSION

Renewed national interest in trust in health care should focus on the capacity to measure it. This review informs the effort to test trust measures for use in research, practice improvement, and value-based payment. Measuring trust, how it relates to outcomes, and learning how it is produced or lost are key to assisting practices and health systems toward earning it.

Primary care provider perspectives on the role of community pharmacy in colorectal cancer screening: a qualitative study

BACKGROUND

The United States Preventive Services Task Force (USPSTF) lists 32 grade A or B recommended preventive services for non-pregnant United States (US) adults, including colorectal cancer screening (CRC). Little guidance is given on how to implement these services with consistency and fidelity in primary care. Given limited patient visit time and competing demands, primary care providers (PCPs) tend to prioritize a small subset of these recommendations. Completion rates of some of these services, including CRC screening, are suboptimal. Expanding delivery of preventive services to other healthcare providers, where possible, can improve access and uptake, particularly in medically underserved areas or populations. Fecal immunochemical testing (FIT) (at-home, stool-based testing) for CRC screening can be distributed and resulted without PCP involvement. Pharmacists have long delivered preventive services (e.g., influenza vaccination) and may be a good option for expanding CRC screening delivery using FIT, but it is not clear how PCPs would perceive this expansion.

METHODS

We used semi-structured interviews with PCPs in North Carolina and Washington state to assess perceptions and recommendations for a potential pharmacy-based FIT distribution program (PharmFIT™). Transcripts were coded and analyzed using a hybrid inductive-deductive content analysis guided by the Consolidated Framework for Implementation Research (CFIR) to elucidate potential multi-level facilitators of and barriers to implementation of PharmFIT™.

RESULTS

We completed 30 interviews with PCPs in North Carolina (N = 12) and Washington state (N = 18). PCPs in both states were largely accepting of PharmFIT™, with several important considerations. First, PCPs felt that pharmacists should receive appropriate training for identifying patients eligible and due for FIT screening. Second, a clear understanding of responsibility for tracking tests, communication, and, particularly, follow-up of positive test results should be established and followed. Finally, clear electronic workflows should be established for relay of test result information between the pharmacy and the primary care clinic.

CONCLUSION

If the conditions are met regarding pharmacist training, follow-up for positive FITs, and transfer of documentation, PCPs are likely to support PharmFIT™ as a way for their patients to obtain and complete CRC screening using FIT.

Is patients' trust in clinicians related to patient-clinician racial/ethnic or gender concordance?

OBJECTIVE

To examine the relationship between patient-clinician concordance (racial/ethnic and gender) and patients' trust in their regular clinician.

METHODS

This mixed methods study used the 2019 U.S. Health Reform Monitoring Survey to examine concordance and patient trust in clinicians, and semi-structured interviews with 24 participants to explore patients' perceptions of how concordance relates to trust in their clinician.

RESULTS

Almost six in ten adults (59.8%) who had a regular clinician reported having trust in their clinician. White, Black, and Latino participants were similarly likely to report trust. Those with racial/ethnic concordant clinicians were 7.5 percentage points more likely to report trust than were those with non-concordant clinicians (62.4% vs 54.9%). This finding was consistent for men and women, and did not differ significantly across racial and ethnic groups. In interviews, while almost all participants described having trusted non-racial/ethnic concordant clinicians, several described immediately trusting concordant clinicians. In contrast, we did not observe a consistent relationship between patient-clinician gender concordance and trust.

CONCLUSION

The findings underscore the importance of increasing the number of Black and Latino clinicians, and also highlight that all clinicians need to work hard to build trust with patients from different racial/ethnic backgrounds.

Message Framing for Men? Gender Moderated Effects of Culturally Targeted Message Framing on Colorectal Cancer Screening Receptivity among African Americans

Receptivity to recommended colorectal cancer (CRC) screening can be enhanced by use of loss-framed health messaging that emphasizes possible consequences of failing to act. However, a simultaneous use of culturally targeted messaging may be needed to achieve effectiveness when loss-framed messaging is used with African Americans, especially to reduce racism-related cognitions aroused by standard loss framing that impede CRC screening receptivity. This study considered whether effects of stand-alone and culturally targeted message framing on CRC screening receptivity differ between African American men and women. African Americans eligible for CRC screening (Men=117, Women=340) viewed an informational video about CRC risks, prevention, and screening, and were randomized to receive a gain or loss-framed message about screening. Half of participants received an additional culturally targeted message. Using the Theory of Planned Behavior, we measured receptivity to CRC screening. We also measured arousal of racism-related cognitions. A significant three-way interaction suggested effects of messaging on CRC screening receptivity were moderated by gender. Participants were no more receptive to CRC screening when standard loss-framing was used, but were more favorable if loss-framing was culturally targeted. However, these effects were more pronounced among African American men. Contrary to prior findings, gender moderated effects of culturally targeted loss-framed messaging were not attributable to reducing racism-related cognitions. Findings add to growing recognition of important nuance in effective use of message framing to also include gender, while suggesting a critical need to explore gender-relevant mechanistic pathways, potentially including how health messaging activates masculinity-related cognitions among African American men.

Reducing disparities and achieving health equity in colorectal cancer screening

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

Barriers in Healthcare for Latinx Patients with Limited English Proficiency-a Narrative Review

Latinx (includes Hispanics and is the non-gendered term for Latino/Latina which is a person of Latin American origin or descent) constitutes the largest racial and ethnic minority group in the United States (US). Many members of this group report limited English proficiency, experience discrimination, feel distrust in the healthcare setting, and face poorer health outcomes than non-Latinx Whites. As healthcare systems assess internal structures of care, understanding the experiences of Latinx patients may inform strategies to improve care. This narrative review describes studies that assessed the experiences of Latinx patients with limited English proficiency (LEP) in the inpatient and outpatient settings in the US. We searched PubMed for studies published between January 1, 1990, and March 2021. We reviewed all citations and available abstracts (n = 429). We classified study titles (n = 156) as warranting detailed consideration of the original article. Limited English proficiency is a well-documented challenge reported by Latinx patients seeking care in the outpatient setting, resulting in mistrust of healthcare organizations and clinicians. The effects of LEP overlap substantially with challenges related to patients' immigration status, cultural traditions, and socioeconomic needs. Use of professional interpretation rather than ad hoc interpretation improves trust and satisfaction. There is no consensus about the most effective mode of delivering professional interpretation (in person, telephonic, video conferencing), although rapid simultaneous telephone translation is a promising modality. Increasing awareness of the barriers to effective communication, improving skills in communicating through translators, and increasing the amount of time spent with patients may improve communication and trust more than structural changes like mode of translation or bedside rounding. Cultural fluency training, standardized language training for providers, and incentive pay for fluency are also deserving of further consideration.

COVID-19 vaccination and race – A nationwide survey of vaccination status, intentions, and trust in the US general population

BACKGROUND: COVID-19 vaccine hesitancy for adults and children varies depending on societal factors, race, and trust ascribed to the source of vaccine information. OBJECTIVE: To assess COVID-19 vaccination rates and trust levels for vaccine information by race at 2 time points. METHODS: Online cross-sectional data from US adults were collected in February/March 2021 (T1) and November 2021 (T2). Questions included vaccination status, reasons for vaccine refusal, trust levels for vaccine information and the Wake Forest Physician Trust Scale. At T2, parents were asked about vaccination status of children aged 12-18 years and intent for children aged 5-11 years. Vaccination rates and trust levels for vaccine information were measured. Multivariable logistic regression was used to identify characteristics predictive of receiving COVID-19 vaccination. RESULTS: Vaccination rates were 20.2% and 70.8% at T1 and T2, respectively. At T1 and T2, higher proportions of White (23.2% and 72.0%) and Other race (14.4% and 75.2%) respondents were vaccinated relative to Black respondents (9.6% and 64.4%) (P < 0.05). In descending order, respondents' doctors, family members, and pharmacists were the most trusted information sources. Black parents, relative to White and Other parents with unvaccinated children aged 12-18 years or who were not very likely to vaccinate younger children, reported lowest physician trust (P < 0.01). At T1, being married, college educated, and older and having greater Wake Forest Physician Trust Scale scores and a higher number of comorbidities predicted a higher likelihood of being vaccinated. Being Black, having a median household income less than $100,000, and residing in the Northeast or Midwest, relative to the West, predicted a decreased likelihood of being vaccinated. At T2, race and comorbidities were no longer predictive of vaccination. CONCLUSIONS: Racial variation in vaccination status decreased from T1 to T2. Physician trust predicted vaccination status and intent regardless of race. Respondents' doctors, family members, and pharmacists are trusted sources of vaccine information, and targeting these influencers may reduce vaccination hesitancy. DISCLOSURES: Dr Brown reports personal fees from Taiho Oncology, outside the submitted work. Dr Morlock reports personal fees from Johnson and Johnson, Heron Therapeutics, Evofem Biosciences, Horizon Therapeutics, and Taiho Oncology, outside the submitted work. Amy Morlock reports personal fees from both AbbVie (formerly Allergan) and Ironwood, outside the submitted work. Drs Blakolmer and Heidari have nothing to disclose.

Association between COVID-19 vaccine hesitancy and trust in the medical profession and public health officials

One's personal physician, national and state or local public health officials, and the broader medical profession play important roles in encouraging vaccine uptake for COVID-19. However, the relationship between trust in these experts and vaccine hesitancy has been underexplored, particularly among racial/minority groups where historic medical mistrust may reduce uptake. Using an April 2021 online sample of US adults (n = 3041) that explored vaccine hesitancy, regression models estimate levels of trust in each of these types of experts and between trust in each of these experts and the odds of being COVID-19 vaccine takers vs refusers or hesitaters. Interaction terms assess how levels of trust in the medical profession by race/ethnicity are associated with vaccine hesitancy. Trust in each expert is positively associated with trust in other experts, except for trust in the medical profession. Only trust in one's own doctor was associated with trust in the medical profession, as measured by factor scores derived from a validated scale. Lower levels of trust in experts were significantly associated with being either a hesitater or a refuser compared to being a taker. Black respondents had higher odds of being either a hesitater or a refuser compared to white respondents but the interaction with trust was insignificant. For Hispanic respondents only, the odds of being a hesitater declined significantly when trust in the medical profession rose. Mistrust in the medical profession, one's doctor and national experts contributes to vaccine hesitancy. Mobilizing personal physicians to speak to their own patients may help.

Factors influencing uptake of diabetes health screening: a mixed methods study in Asian population

BACKGROUND

Health screens are the cornerstones for health promotion and preventive interventions at a community level. This study investigated the barriers and facilitators to the uptake of diabetes health screening in the general population of Singapore.

METHODS

In this mixed methods study, participants without diabetes were recruited from the general population. The quantitative phase (n = 2459) included face to face survey of participants selected through disproportionate stratified random sampling. Those who participated in the quantitative survey were then randomly chosen for a one-to-one semi-structured interview (n = 30).

RESULTS

Among the survey respondents, 73.09% (n = 1777) had attended a diabetes health screening in their lifetime whilst 42.36% (n = 1090) and 57.64% (n = 1328, p < 0.0001) attended the health screens regularly (every 12 months) and irregularly, respectively. A significantly higher proportion of older adults (≥ 40 years) attended regular diabetes health screening compared to younger adults (less than 40 years; 55.59% vs 24.90%, p < 0.001). The top 3 reasons for attending regular health screens were to detect diabetes early, to make lifestyle changes in case of a diagnosis and being health conscious. Qualitative interviews identified similar issues and complex nuances that influenced the uptake of regular diabetes health screening. Several personal factors (laziness, self-reliance, psychological factors, etc.), competing priorities, fatalistic beliefs, affordability, misconceptions about the screens, and appointment related factors (inconvenient location, time, etc.) were identified as barriers, while affordable screens, sense of personal responsibility, perception of susceptibility /risk, role of healthcare team (e.g. reminders and prescheduled appointments) and personal factors (e.g. age, family, etc.) were facilitators. Age, household income, ethnicity and educational level were associated with the uptake of regular diabetes health screening.

CONCLUSION

The uptake of regular diabetes health screening can be improved. Several barriers and enablers to the uptake of diabetes health screening were identified which should be addressed by the policy makers to alleviate misconceptions and create greater awareness of the importance of the programme that will improve participation.

Decision Support Needs for Patients with Severe Symptomatic Aortic Stenosis

Social workers in healthcare settings often support patient decision-making processes for complex medical decisions. The objective of this study was to examine decision support needs for patients considering aortic valve replacement (AVR) for aortic stenosis. Seventeen qualitative interviews were conducted to explore treatment decision experiences of patients who accepted AVR. Analysis was conducted using a mixed inductive-deductive approach. Fear was a prevalent response for most participants in the face of AVR. Two general paths of decision making emerged: an "active" information seeking approach, or a "passive" simplicity seeking approach. Patients with unique clinical presentations felt alienated by the decision-making process. Acknowledging fear while understanding different decision-making styles provide opportunities for social workers and other members of multidisciplinary teams to support complex patient decisions.

Trust in Physicians, Anxiety and Depression, and Decision-Making Preferences among Parents of Children with Serious Illness

Objective: To assess parental decision-making preferences when caring for a child with serious illness and to evaluate for an association between preferences and parental trust in physicians, and potential modification of this association by parental anxiety or depression. Methods: We analyzed cross-sectional data from 200 parents of 158 children in the United States who had life-threatening illnesses and whose attending physicians thought that the parents would have to make major medical decision in the next 12 to 24 months. Parents completed measures of decision-making preferences, trust in physicians, anxiety, and depression. Results: Higher reported levels of trust were associated with lower preferences for autonomous decision making (Spearman correlation = -0.24; 95% confidence interval [CI] = -0.36 to -0.01; p < 0.008). Among parents with higher levels of trust, increasing anxiety scores were associated with decreasing preference for autonomy, whereas among parents with lower levels of trust, increasing anxiety scores showed an increasing preference for autonomy (regression coefficient = -0.01; 95% CI = -0.02 to -0.001; p ≤ 0.03). Conclusions: Decreasing trust in physicians is associated with a higher preference for autonomous decision making. Parents who have higher levels of anxiety exhibit this association more strongly. Decision support for parents of children with serious illness should use strategies to respect parental decision-making preferences, address potential distrust, and provide mental health support to parents who are anxious or depressed.

Trust and Distrust in Opioid Decision-Making: A Qualitative Assessment of Patient-Doctor Relationship

PURPOSE

Surgeons often prescribe opioid analgesics for pain management after surgery. However, we understand little about how patients perceive opioid prescribing and make decisions to use opioids for postoperative pain management. In this study, we aimed to gain an understanding of patients' decision-making process on postoperative opioid use.

METHODS

We conducted semi-structured interviews with 30 adult patients undergoing elective surgery at our institution. The interviews were content-coded for thematic analysis. We used trust in the medical setting as a conceptual framework to interpret and find the inherent theory in the data.

RESULTS

We found that participants based their opioid decisions on their trust or distrust toward various elements of their postoperative pain management. Participants believed that the surgeons "know," thereby, reinforcing their trust in surgeons' postoperative opioid prescribing to be in the participants' best interest. Moreover, the positive reputation of the institution strengthened the participants' trust. However, participants conveyed nuanced trust because of their distrust toward the opioid medications themselves, which were viewed as "suspicious," and the pharmaceutical companies, that were "despised." Despite this distrust, participants had confidence in their inherent ability to protect themselves from opioid use disorders.

CONCLUSIONS

Understanding how patients perceive and form decisions on postoperative opioid use based on their trust and distrust toward various factors involved in their care highlights the importance of the patient-doctor relationship and building trust to effectively address postoperative pain and reduce opioid-related harms.

CLINICAL RELEVANCE

Through a strengthened therapeutic alliance between patients and surgeons, we can improve our strategies to overcome the ongoing opioid epidemic through patient-centered approaches.

Screening and prevention of colorectal cancer

Mortality from colorectal cancer is reduced through screening and early detection; moreover, removal of neoplastic lesions can reduce cancer incidence. While understanding of the risk factors, pathogenesis, and precursor lesions of colorectal cancer has advanced, the cause of the recent increase in cancer among young adults is largely unknown. Multiple invasive, semi- and non-invasive screening modalities have emerged over the past decade. The current emphasis on quality of colonoscopy has improved the effectiveness of screening and prevention, and the role of new technologies in detection of neoplasia, such as artificial intelligence, is rapidly emerging. The overall screening rates in the US, however, are suboptimal, and few interventions have been shown to increase screening uptake. This review provides an overview of colorectal cancer, the current status of screening efforts, and the tools available to reduce mortality from colorectal cancer.

Building Patient Trust in Hospitals: A Combination of Hospital-Related Factors and Health Care Clinician Behaviors

BACKGROUND

Patients' trust in their regular clinician is relatively high in the United States, but trust in the health care system and in key institutions, such as hospitals, is considerably lower. The purpose of this study was to identify the factors that build patients' trust in hospitals.

METHODS

In early 2020 the authors conducted 38 semistructured telephone interviews with participants across the United States. Respondents were asked about trust in hospitals generally, as well as what makes them trust and not trust specific hospitals. Interviews were audio recorded, transcribed, and analyzed using a descriptive thematic approach.

RESULTS

Participants identified three mechanisms through which hospitals build their trust: (1) competence (effectively treating health issues, providing a safe and clean hospital environment, and having clinicians who are knowledgeable and thorough), (2) caring (hospital culture that prioritizes patients' comfort, welcoming physical environment, and clinicians who are compassionate), and (3) communication (hospital culture of listening to patients and explaining clearly, particularly with treatment and discharge plans). The absence of these three factors resulted in loss of trust. Hospital cost also lost patients' trust in hospitals. While the cost of hospital care affected some participants' overall level of trust in hospitals, others separated the trust they had in the medical care received from trust in billing practices.

CONCLUSION

The findings underscore the importance of perceived quality of care and hospital safety/hygiene, as well as having an organizational culture that emphasizes caring and effective communication, for building patient trust.

Patients' Willingness to Share Limited Endoscopic Resources: A Brief Report on the Results of a Large Regional Survey

Background. In some health care systems, patients face long wait times for screening colonoscopy. We sought to assess whether patients at low risk for colorectal cancer (CRC) would be willing to delay their own colonoscopy so higher-risk peers could undergo colonoscopy sooner. Methods. We surveyed 1054 Veterans regarding their attitudes toward repeat colonoscopy and risk-based prioritization. We used multivariable regression to identify patient factors associated with willingness to delay screening for a higher-risk peer. Results. Despite a physician recommendation to stop screening, 29% of respondents reported being "not at all likely" to stop. However, 94% reported that they would be willing to delay their own colonoscopy for a higher-risk peer. Greater trust in physician and greater health literacy were positively associated with willingness to wait, while greater perceived threat of CRC and Black or Latino race/ethnicity were negatively associated with willingness to wait. Conclusion. Despite high enthusiasm for repeat screening, patients were willing to delay their own colonoscopy for higher-risk peers. Appealing to altruism could be effective when utilizing scarce resources.

A Mixed Methods Examination of Health Care Provider Behaviors That Build Patients' Trust

OBJECTIVE

Patient trust in health care providers is associated with better health behaviors and utilization, yet provider trust has not been consistently conceptualized. This study uses qualitative methods to identify the key health provider behaviors that patients report build their trust, and data from a national U.S. survey of adults to test the robustness of the qualitative findings.

METHODS

In this mixed methods study, we conducted 40 semi-structured interviews with a diverse sample to identify the provider behaviors that build trust. We then analyzed a nationally representative survey (n = 6,517) to examine the relationship between respondents' trust in their usual provider and the key trust-related behaviors identified in the qualitative interviews.

RESULTS

Interviewees reported that health providers build trust by communicating effectively (listening and providing detailed explanations), caring about their patients (treating them as individuals, valuing their experience, and showing commitment to solving their health issues), and demonstrating competence (being knowledgeable, thorough, and solving their health issues). Trust in one's provider was highly correlated with all eight survey items measuring communication, caring, and competence.

CONCLUSIONS

To build trust with patients, health providers should actively listen, provide detailed explanations, show caring for patients, and demonstrate their knowledge.

How Public Trust in Health Care Can Shape Patient Overconsumption in Health Systems? The Missing Links

Overconsumption of health care is an ever-present and complex problem in health systems. It is especially significant in countries in transition that assign relatively small budgets to health care. In these circumstances, trust in the health system and its institutions is of utmost importance. Many researchers have studied interpersonal trust. Relatively less attention, however, has been paid to public trust in health systems and its impact on overconsumption. Therefore, this paper seeks to identify and examine the link between public trust and the moral hazard experienced by the patient with regard to health care consumption. Moreover, it explores the mediating role of patient satisfaction and patient non-adherence. For these purposes, quantitative research was conducted based on a representative sample of patients in Poland. Interesting findings were made on the issues examined. Patients were shown not to overconsume health care if they trusted the system and were satisfied with their doctor-patient relationship. On the other hand, nonadherence to medical recommendations was shown to increase overuse of medical services. The present study contributes to the existing knowledge by identifying phenomena on the macro (public trust in health care) and micro (patient satisfaction and non-adherence) scales that modify patient behavior with regard to health care consumption. Our results also provide valuable knowledge for health system policymakers. They can be of benefit in developing communication plans at different levels of local government.

The role of trust in HPV vaccine uptake among racial and ethnic minorities in the United States: a narrative review

Despite the clinically proven benefits of the human papillomavirus (HPV) vaccine in preventing cervical and other HPV-associated cancers, vaccination coverage has been suboptimal among adolescents and young adults in the United States (US), particularly among racial and ethnic minority adolescents. Historical legacies, combined with current racial/ethnic disparities in healthcare, may contribute to suboptimal uptake and completion of the HPV vaccine in part through differing levels of trust in doctors and healthcare institutions. The purpose of this narrative review was to characterize trust and its role in decision making about HPV vaccine uptake among US racial and ethnic minorities. We conducted a literature search using the PubMed database, and our search terms yielded 1176 articles. We reviewed 41 full-text articles for eligibility and included 20 articles in this review. These studies used varied measures of trust or mistrust and assessed trust in not only doctors/healthcare providers, but also other sources including pharmaceutical companies, media, and clergy. Our review findings revealed generally high levels of trust in doctors and healthcare providers, but less so in pharmaceutical companies. Mistrust of either healthcare providers, government agencies or pharmaceutical companies was consistently associated with less favorable attitudes and lower vaccine uptake. The downstream effects of mistrust may occur through selected health beliefs regarding the perceived efficacy and safety of the vaccine. Minority groups were more likely to report trust in family members, religious organizations, and media sources compared to their white counterparts. Decision making about vaccine uptake is a multilayered process that involves comparing the perceived benefits of the vaccine against its perceived risks. Understanding how trusted sources can effectively harness the tools of social and traditional media to increase knowledge and awareness may help combat misinformation about the HPV vaccine and improve engagement with diverse communities.

Perceptions of and Barriers to Lung Cancer Screening Among Physicians in Puerto Rico: A Qualitative Study

Low-dose computed tomography (LDCT), an accepted U.S. screening tool for early lung cancer detection, is not widely-used in Puerto Rico. We investigated knowledge and attitudes about LDCT in focus groups of primary care physicians (PCP) and individuals at high risk for lung cancer (HRI) in Puerto Rico. Transcribed/translated audio-recorded discussions were analyzed with the constant comparison method. Both groups had limited knowledge about LDCT and concerns regarding insurance coverage. Most HRIs had never had a provider recommend LDCT and believed that having symptoms was necessary to obtain LDCT screening. Perceived barriers included fears about results and the procedure; a perceived benefit was having early detection and possibly being cured. Few PCPs had ever recommended LDCT to a patient, with those who had basing their decision on symptoms/smoking history but having challenges with insurance. More education on LDCT is needed among HRIs, and U.S. Preventive Services Task Force guidelines should be widely distributed to encourage physician recommendations.

Impact of Health Insurance, Poverty, and Comorbidities on Colorectal Cancer Screening: Insights from the Medical Expenditure Panel Survey

BACKGROUND

Despite national campaigns and other efforts to improve colorectal cancer (CRC) screening, participation rates remain below targets set by expert panels. We hypothesized that availability and practice patterns of healthcare providers may contribute to this gap.

METHOD

Using data of the Medical Expenditure Panel Survey for the years between 2000 and 2016, we extracted demographic, socioeconomic, and health-related data as well as reported experiences about barriers to care, correlating results with answers about recent participation in colorectal cancer screening. As CRC screening guidelines recommend initiation of testing at age 50, we focused on adults 50 years or older.

RESULTS

We included responses of 163,564 participants for the period studied. There was a significant increase in CRC screening rates over time. Comorbidity burden, poverty, race, and ethnicity independently predicted participation in screening. Lack of insurance coverage and cost of care played an important role as reported barrier. Convenient access to care, represented by availability of appointments beyond typical business hours, and frequency of provider interactions, correlated with higher rates of screening.

CONCLUSION

Our data show a positive effect of educational efforts and healthcare reform with coverage of screening. Easy and more frequent access to individual providers predicted a higher likelihood of completed screening tests. This finding could translate into more widespread implementation of screening programs, as the increasingly common virtual care delivery offers a new and convenient option to patients.

Modelling health care customer satisfaction: Evidence from Serbia

Customer loyalty, with satisfaction of customers as its main precondition, has long been regarded as an overarching goal of service businesses. With the proliferation of health care providers, which brought about rising competitive pressures on the market, the issue of how to satisfy and keep patients has been attracting increasing attention of researchers and health care management. Therefore, this study aims to examine the antecedents of patient satisfaction and its direct and mediated impact on patients' behavioural intentions in thus far under-studied context of emerging economy's health care system. The study has been conducted in a primary health care setting, on a convenience sample of 300 patients, by means of structured questionnaire. The application of structural equation modelling (SEM) revealed direct impact of health care service quality on patient satisfaction and its mediated impact on satisfaction, via perceived value of health care services. In addition to direct influence of satisfaction on patients' behavioural intentions, its total effect on positive intentions of patients is increased by the impact of patient commitment to a health care provider, which, as evidenced by this study's findings, increases with patient's rising trust into a health care provider. Implications for theory and practice are discussed and further research directions are provided.

A Motivational Interviewing Intervention to Promote CRC Screening: A Pilot Study

BACKGROUND

Appalachian Kentuckians suffer a disproportionate incidence and mortality from colorectal cancer (CRC) and are screened at lower rates (35%) compared with 47% of Kentuckians.

OBJECTIVE

The aim of this study was to evaluate the efficacy of a motivational interviewing intervention delivered by trained Lay Health Advisors on CRC screening.

METHOD

Eligible participants recruited from an emergency department (ED) completed a baseline survey and were randomized to either the control or the motivational interviewing intervention provided by Lay Health Advisors. Follow-up surveys were administered 3 and 6 months after baseline. To evaluate potential differences in treatment and control groups, t tests, χ, and Mann-Whitney U tests were used.

RESULTS

At either the 3- or 6-month assessment, there was no difference in the CRC screening by group (χ = 0.13, P = .72). There was a significant main effect for the study group in the susceptibility to CRC model; regardless of time, those in the intervention group reported approximately 1-point higher perceived susceptibility to CRC, compared with controls (est. b = 0.68, P = .038). Age and financial adequacy had a significant effect related to CRC screening. Older participants (est. b = 0.09, P = .014) and those who reported financial inadequacy (est. b = 2.34, P = .002) reported more screening barriers.

CONCLUSION

This pilot study elucidated important factors influencing the uptake of CRC for an ED transient population and this may be useful in the design of future interventions using motivational interviewing in EDs.

IMPLICATIONS FOR PRACTICE

Nurses can provide information about CRC screening guidelines and provide referrals to appropriate screening resources in the community.

Black and White Differences in Colorectal Cancer Screening and Screening Outcomes: A Narrative Review

Racial disparities in colorectal cancer incidence are widely documented. There are two potential mechanisms for these disparities: differences in access to screening, including screening follow-up, and differences in underlying risk of colorectal cancer. We reviewed the literature for evidence of these two mechanisms. We show that higher colorectal cancer incidence in blacks relative to whites emerged only after the dissemination of screening and describe evidence of racial disparities in screening rates. In contrast to the strong evidence for differences in colorectal cancer screening utilization, there is limited evidence for racial differences in adenoma prevalence. In general, black and white patients who are screened have similar adenoma prevalence, though there is some evidence that advanced adenomas and adenomas in the proximal colon are somewhat more likely in black than white patients. We conclude that higher rates of colorectal cancer incidence among black patients are primarily driven by lower rates of colorectal cancer screening. Our findings highlight the need to increase black patients' access to quality screening to reduce colorectal cancer incidence and mortality.

Association of Patients' Perception of Quality of Healthcare Received and Colorectal Cancer Screening Uptake: An Analysis of 2 National Surveys in the USA

OBJECTIVE

It is not known whether patients' ratings of the quality of healthcare services they receive truly correlate with the quality of care from their providers. Understanding this association can potentiate improvement in healthcare delivery. We evaluated the association between patients' ratings of the quality of healthcare services received and uptake of colorectal cancer (CRC) screening.

SUBJECTS AND METHODS

We used 2 iterations of the Health Information National Trends Survey (HINTS) of adults in the USA. HINTS 2007 (4,007 respondents; weighted population = 75,397,128) evaluated whether respondents were up to date with CRC screening while HINTS 4 cycle 3 (1,562 respondents; weighted population = 76,628,000) evaluated whether participants had ever received CRC screening in the past. All included respondents from both surveys were at least 50 years of age, had no history of CRC, and had rated the quality of healthcare services that they had received at their healthcare provider's office in the previous 12 months.

RESULTS

HINTS 2007 data showed that respondents who rated their healthcare as good or fair/poor were significantly less likely to be up to date with CRC screening compared to those who rated their healthcare as excellent. We found comparable results from analysis of HINTS 4 cycle 3 data with poorer uptake of CRC screening as the healthcare quality ratings of respondents reduced.

CONCLUSION

Our study suggests that patients who reported receiving lower quality of healthcare services were less likely to have undergone and be compliant with CRC screening recommendations. It is important to pay close attention to patient feedback surveys in order to improve healthcare delivery.

Insurance status and level of education predict disparities in receipt of treatment and survival for anal squamous cell carcinoma

INTRODUCTION

Anal squamous cell carcinoma (ASCC) is relatively rare, but its incidence and mortality have been steadily climbing in marginalized populations. We explored the impact of insurance status, education, and income on survival and receipt of chemoradiation therapy.

METHODS

We included patients with ASCC from the Surveillance, Epidemiology, and End Results Program database from 2004 to 2016. Socioeconomic variables included insurance status, level of education, income, and unemployment rate. Cox proportional hazards and multivariate logistic regression were used to determine predictors of survival and receipt of chemoradiation.

RESULTS

We included a total of 10,868 cases of ASCC. The median age was 55, 10.4 % were black, and 65.4 % were female. Overall, 74.1 % of patients received combination chemoradiation. In multivariate analysis, poorer survival was found for Medicaid (HR 1.52, 95 % CI 1.34-1.74) and uninsured (HR 1.68, 95 % CI 1.35-2.10) patients, and for communities with the lowest rates of high school education (HR 1.17, 95 % CI 1.02-1.38), lowest income (HR 1.29, 95 % CI 1.08-1.54), and highest unemployment (HR 1.21, 95 % CI 1.03-1.40). Patients were less likely to receive combination treatment if they were black (OR 0.76, 95 % CI 0.55-0.92), had Medicaid insurance (OR 0.54, 95 % CI 0.33-0.88) or lower education (OR 0.59, 95 % CI 0.46-0.76).

CONCLUSION

Insurance status, level of education, income, and employment impact survival and receipt of treatment in patients with ASCC. Identifying high risk patients and developing targeted interventions to improve access to treatment is integral to reducing these disparities and improving cancer survival.

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

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

Patient-physician relationships, health self-efficacy, and gynecologic cancer screening among women with Lynch syndrome

Background

Lynch syndrome, a hereditary cancer syndrome, predisposes women to colorectal, endometrial, and ovarian cancer. Current guidelines recommend that women with Lynch syndrome undergo risk-reducing gynecological surgery to reduce their chances of developing endometrial or ovarian cancer. Little is known about how women with Lynch syndrome perceive gynecological cancer screening, or the psychosocial factors associated with screening attitudes and behaviour.

Methods

This study used a cross-sectional, quantitative design. Using self-report questionnaire data from a sample of women with Lynch syndrome (N = 50) who had not undergone risk-reducing surgery, the current study sought to: 1) describe the gynecological cancer screening behaviours of women with Lynch syndrome, as well participant-reported sources of information about Lynch syndrome; 2) examine the extent to which women believe gynecological cancer screening is effective and provides them with reassurance and; 3) assess to what extent relationships with one’s family physician were associated with gynecological cancer screening, perceptions about screening, and health self-efficacy. Data were analyzed using descriptive statistics and Spearman rank-ordered correlations.

Results

Data analyses showed that transvaginal ultrasound was the most common screening behaviour (57%) followed by pelvic ultrasound (47%). Only 22% of participants underwent endometrial biopsy. Patient-physician relationships were related to greater health self-efficacy to manage Lynch syndrome and greater perceived effectiveness of gynecological screening. However, health self-efficacy and better patient-physician relationships were not associated with increased engagement in gynecological cancer screening.

Conclusions

The data suggest that feeling efficacious about managing one’s Lynch syndrome and screening is related to positive interactions and communication with one’s family physician. While this is encouraging, future research should examine educating both family physicians and patients about current guidelines for Lynch syndrome gynecological screening recommendations.

How narratives influence colorectal cancer screening decision making and uptake: A realist review

BACKGROUND

Although narratives have been found to affect decisions about preventive behaviours, including participation in cancer screening, the underlying mechanisms of narratives remain unclear.

OBJECTIVE

The purpose of this study was to summarize and synthesize existing literature on narrative interventions in the context of colorectal cancer screening. Our main research question was as follows: How, when and for whom do narratives work context of decision making about colorectal cancer screening participation?

METHODS

We undertook a realist review to collect evidence on narratives in the context of colorectal cancer screening. A search of the literature was performed in Embase, MEDLINE/PubMed, Cinahl and PsycINFO. We included empirical evaluations (qualitative or quantitative) of narrative interventions. In total, 15 studies met the inclusion criteria. A content-based taxonomy of patient narrative types in decision aids formed the basis for our initial programme theory.

MAIN RESULT

We identified four mechanisms: (a) process narratives that address perceived barriers towards screening lead to improved affective forecasting, (b) experience narratives that demonstrate the screening procedure lead to increased self-efficacy, (c) experience narratives that depict experiences from similar others lead to more engagement and (d) outcome narratives that focus on outcomes of colorectal cancer (CRC) screening decision decrease or increase fear of colorectal cancer. The evidence was limited on which narrative type may facilitate or bias informed decision making in colorectal cancer screening.

DISCUSSION AND CONCLUSION

The findings indicate the importance of more detailed descriptions of narrative interventions in order to understand how mechanisms may facilitate or bias informed decision making in colorectal cancer screening.

Public Trust in Physicians-Health Care Commodification as a Possible Deteriorating Factor: Cross-sectional Analysis of 23 Countries

Trust in physicians has declined, and surveys of public opinion show a poor level of public trust in physicians. Commodification of health care has been speculated as a plausible driving force. We used cross-national data of 23 countries from the International Social Survey Programme 2011 to quantify health care commodification and study its role in the trust that patients generally place in physicians. A modified health care index was used to quantify health care commodification. There were 34 968 respondents. A question about the level of general trust in physicians and a 4-item “general trust in physicians” scale were used as our major and minor outcomes. The results were that compared with those in the reference countries, the respondents in the health care–commodified countries were approximately half as likely to trust physicians (odds ratio: 0.47, 95% confidence interval [CI]: 0.31-0.72) and scored 1.13 (95% CI: 1.89-0.37) less on the general trust scale. However, trust in physicians in the health care–decommodified countries did not differ from that in the reference countries. In conclusion, health care commodification may play a meaningful role in the deterioration of public trust in physicians.

Repeated Automated Mobile Text Messaging Reminders for Follow-Up of Positive Fecal Occult Blood Tests: Randomized Controlled Trial

Background

Fecal occult blood tests (FOBTs) are recommended by the US Preventive Services Task Force as a screening method for colorectal cancer (CRC), but they are only effective if positive results are followed by colonoscopy. Surprisingly, a large proportion of patients with a positive result do not follow this recommendation.

Objective

The objective of this study was to examine the effectiveness of text messaging (short message service, SMS) in increasing adherence to colonoscopy follow-up after a positive FOBT result.

Methods

This randomized controlled trial was conducted with patients who had positive CRC screening results. Randomization was stratified by residential district and socioeconomic status (SES). Subjects in the control group (n=238) received routine care that included an alert to the physician regarding the positive FOBT result. The intervention group (n=232) received routine care and 3 text messaging SMS reminders to visit their primary care physician. Adherence to colonoscopy was measured 120 days from the positive result. All patient information, including test results and colonoscopy completion, were obtained from their electronic medical records. Physicians of study patients completed an attitude survey regarding FOBT as a screening test for CRC. Intervention and control group variables (dependent and independent) were compared using chi-square test. Logistic regression was used to calculate odds ratios (ORs) and 95% CIs for performing colonoscopy within 120 days for the intervention group compared with the control group while adjusting for potential confounders including age, gender, SES, district, ethnicity, and physicians’ attitude.

Results

Overall, 163 of the 232 patients in the intervention group and 112 of the 238 patients in the control group underwent colonoscopy within 120 days of the positive FOBT results (70.3% vs 47.1%; OR 2.17, 95% CI 1.49-3.17; P<.001); this association remained significant after adjusting for potential confounders (P=.001).

Conclusions

A text message (SMS) reminder is an effective, simple, and inexpensive method for improving adherence among patients with positive colorectal screening results. This type of intervention could also be evaluated for other types of screening tests.

Trial Registration

ClinicalTrials.gov NCT03642652; https://clinicaltrials.gov/ct2/show/NCT03642652 (Archived by WebCite at http://www.webcitation.org/74TlICijl)

Is the patient activation measure associated with adherence to colonoscopy after a positive fecal occult blood test result?

BACKGROUND

Colorectal cancer (CRC) is a major cause of morbidity and mortality worldwide, but these can be reduced significantly with population screening using annual fecal occult blood tests (FOBT)A positive FOBT requires timely follow-up with colonoscopy to maximize screening benefits.. Several barriers to follow-up have been identified, with patient health behaviors and choices comprising a significant part of these. The Patient Activation Measure (PAM) assesses knowledge, skills, beliefs, and confidence in managing health. Increased patient activation is related to positive health outcomes. The aim of this study is to examine the association between patient empowerment, as reflected in the PAM, and follow-up colonoscopy within 90 days of a positive FOBT result.

METHODS

This case-control study included 429 patients with a positive FOBT, 174 who had a colonoscopy within 90 days, and 255 who did not.. Participants completed a PAM telephone questionnaire (Cronbach's α = 0.785). We used both univariate and multivariate analyses to examine the effect of the PAM score as on the likelihood of undergoing colonoscopy, after adjusting for the independent variables.

RESULTS

In this study we did not find a significant association between PAM and adherence to colonoscopy, using both univariate and multivariate analyses (p = .334 and p = .697, whether PAM was defined as a continuous or as categorical, respectively).

CONCLUSIONS

This study was the first to examine the association between patient empowerment, as reflected in the patient activation measure, and adherence to colonoscopy after a positive FOBT. The findings did not support such an association. Further examination is required to clarify the relation between patient empowerment and activation and personal healthcare in general, and in the Israeli population in particular. Future policy should include specific, technical interventions to improve FOBT follow-up among all groups, until the patient-related barriers are better understood.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02534142 https://clinicaltrials.gov/ct2/show/NCT02534142.

Usefulness of Non-Invasive Fetal RHD Genotyping towards Immunoprophylaxis Optimization

Introduction: Since anti-D immunoprophylaxis given to D-negative pregnant women is a blood product, blood donations have an impact on the availability of prophylactic doses. The Pan American Health Organization reported, in June 2017, that less than half of blood donors are volunteers in Latin America and the Caribbean. In these countries, guidelines for use of anti-D prophylaxis are still controversial. The aim of this study was to demonstrate the convenience of a simple and cost-effectivene non-invasive prenatal diagnostic assay for anti-D prophylaxis optimization in multiethnic populations. Methods: Cell-free fetal DNA from plasma samples of D-negative pregnant women were analyzed by real-time PCR for simultaneous amplification of sequences of exons 5 and 10 of the RHD gene. Fetal RHD genotype was determined in 111 pregnant women. Neonates' phenotype was determined 72 h after birth. Results: Genotyping predicted fetal phenotype with 100% accuracy. Prenatal diagnosis showed 78% RHD-positive and 22% RHD-negative neonates. Conclusion: We demonstrated that, beyond the large genetic variation of the Rh system and the numerous D variants present in multiethnic groups, non-invasive fetal RHD genotyping using two sequences of the gene can be enough for clinical application in an admixed population. This robust technique of simple implementation allows to determine fetal RHD in maternal blood with high sensitivity, specificity, and accuracy. The introduction of fetal RhD genotyping as part of an antenatal screening program constitutes a reliable manner to optimize anti-D prophylaxis; however, it has not been implemented so far in most American countries.

Medical Mistrust and Colorectal Cancer Screening Among African Americans

Despite well-documented benefits of colorectal cancer (CRC) screening, African Americans are less likely to be screened and have higher CRC incidence and mortality than Whites. Emerging evidence suggests medical mistrust may influence CRC screening disparities among African Americans. The goal of this systematic review was to summarize evidence investigating associations between medical mistrust and CRC screening among African Americans, and variations in these associations by gender, CRC screening type, and level of mistrust. MEDLINE, CINAHL, Web of Science, PsycINFO, Google Scholar, Cochrane Database, and EMBASE were searched for English-language articles published from January 2000 to November 2016. 27 articles were included for this review (15 quantitative, 11 qualitative and 1 mixed methods study). The majority of quantitative studies linked higher mistrust scores with lower rates of CRC screening among African Americans. Most studies examined mistrust at the physician level, but few quantitative studies analyzed mistrust at an organizational level (i.e. healthcare systems, insurance, etc.). Quantitative differences in mistrust and CRC screening by gender were mixed, but qualitative studies highlighted fear of experimentation and intrusiveness of screening methods as unique themes among African American men. Limitations include heterogeneity in mistrust and CRC measures, and possible publication bias. Future studies should address methodological challenges found in this review, such as limited use of validated and reliable mistrust measures, examination of CRC screening outcomes beyond beliefs and intent, and a more thorough analysis of gender roles in the cancer screening process.

Identifying Communication Barriers to Colorectal Cancer Screening Adherence among Appalachian Kentuckians

Utilizing data from 40 in-depth interviews, this article identifies both barriers and facilitators to colorectal screening guideline adherence among Appalachian Kentucky adults recruited through a community-based research network. Key findings identify (a) varying levels of knowledge about screening guidelines, (b) reticence to engage in screening processes, and (c) nuanced communication with healthcare providers and family members regarding screening adherence. What participants knew about the screening process was often derived from personal stories or recalled stories from family members about their screening experiences. Reticence to engage in screening processes reflected reports of cumbersome preparation, privacy issues, embarrassment, medical mistrust, fear of receiving a cancer diagnosis, and lack of symptoms. Participants cited many ways to enhance patient-centered communication, and the findings from this study have implications for health communication message design and communication strategies for healthcare practices in Appalachian Kentucky clinics.

Comparative effectiveness of mailed reminders with and without fecal immunochemical tests for Medicaid beneficiaries at a large county health department: A randomized controlled trial

BACKGROUND

Colorectal cancer (CRC) screening is effective but underused. Screening rates are lower among Medicaid beneficiaries versus other insured populations. No studies have examined mailed fecal immunochemical testing (FIT)-based outreach programs for Medicaid beneficiaries.

METHODS

In a patient-level randomized controlled trial, a mailed CRC screening reminder plus FIT, sent from an urban health department to Medicaid beneficiaries, was compared with the same reminder without FIT. The reminder group could request FIT. Completed FIT kits were processed by the health department laboratory. Respondents were notified of normal results by mail. Abnormal results were given via phone by a patient navigator who provided counselling and assistance with follow-up care. The primary outcome was FIT return.

RESULTS

In all, 2144 beneficiaries at average CRC risk were identified, and there was no evidence of screening with Medicaid claims data. To the reminder+FIT group, 1071 were randomized, and 1073 were randomized to the reminder group; 307 (28.7%) in the reminder+FIT group and 347 (32.3%) in the reminder group were unreachable or ineligible (previous screening). The FIT return rate was significantly higher in the reminder+FIT group than the reminder group (21.1% vs 12.3%; difference, 8.8%; 95% confidence interval, 3.7%-13.9%; P < .01). Eighteen individuals (7.2%) who completed FIT tests had abnormal results, and 15 were eligible for follow-up colonoscopy; 66.7% (n = 10) completed follow-up colonoscopy.

CONCLUSIONS

A health department-based, mailed FIT program targeting Medicaid beneficiaries was feasible. Including a FIT kit resulted in greater screening completion than a reminder letter alone. Further research is needed to understand the comparative cost-effectiveness of these interventions.