The practices and attitudes of primary care nurse practitioners and physician assistants with respect to colorectal cancer screening

Understanding primary care nurses' contribution to cancer early diagnosis: A systematic review

PURPOSE

Primary care nurses can contribute to cancer early diagnosis. The objective of this systematic review was to identify, appraise and synthesise evidence on primary care nurses' contribution towards cancer early diagnosis in developed countries.

METHOD

The following databases were searched in September 2017: MEDLINE, PsychINFO, CINAHL, SCOPUS, and EMBASE. Data were extracted on nurses': knowledge of cancer; frequency of 'cancer early diagnosis-related discussions' with patients; and perceived factors influencing these discussions. Studies were appraised using the Mixed Methods Appraisal Tool.

RESULTS

Twenty-one studies were included from: United States, United Kingdom, Ireland, Spain, Turkey, Australia, Brazil and Middle East. Studies were mostly of low quality (one did not meet any appraisal criteria, 15 met one, four met two, and one met three). Nurses' knowledge of cancer, and their frequency of 'cancer early diagnosis-related discussions', varied across countries. This may be due to measurement bias or nurses' divergent roles across healthcare systems. Commonly perceived barriers to having screening discussions included: lack of time, insufficient knowledge and communication skills, and believing that patients react negatively to this topic being raised.

CONCLUSIONS

Findings suggest a need for nurses to be adequately informed about, and have the confidence and skills to discuss, the topic of cancer early diagnosis. Further high-quality research is required to understand international variation in primary care nurses' contribution to this field, and to develop and evaluate optimal methods for preparing them for, and supporting them in, this.

Identifying quality improvement targets to facilitate colorectal cancer screening completion

The colorectal cancer (CRC) screening process involves multiple interfaces (communication exchanges and transfers of responsibility for specific actions) among primary care and gastroenterology providers, laboratory, and administrative staff. After a retrospective electronic health record (EHR) analysis discovered substantial clinic variation and low CRC screening prevalence overall in an urban, integrated safety-net system, we launched a qualitative analysis to identify potential quality improvement targets to enhance fecal immunochemical test (FIT) completion, the system's preferred screening modality. Here, we report examination of organization-, clinic-, and provider-level interfaces over a three-year period (December 2011-October 2014). We deployed in parallel 3 qualitative data collection methods: (1) structured observation (90+ hours, 10 sites); (2) document analysis (n > 100); and (3) semi-structured interviews (n = 41) and conducted iterative thematic analysis in which findings from each method cross-informed subsequent data collection. Thematic analysis was guided by a conceptual model and applied deductive and inductive codes. There was substantial variation in protocols for distributing and returning FIT kits both within and across clinics. Providers, clinic and laboratory staff had differing access to important data about FIT results based on clinical information system used and this affected results reporting. Communication and coordination during electronic referrals for diagnostic colonoscopy was suboptimal particularly for co-morbid patients needing anesthesia clearance. Our multi-level approach elucidated organizational deficiencies not evident by quantitative analysis alone. Findings indicate potential quality improvement intervention targets including: (1) best-practices implementation across clinics; (2) detailed communication to providers about FIT results; and (3) creation of EHR alerts to resolve pending colonoscopy referrals before they expire.

Nonphysician Clinicians in the Follow-Up of Resected Patients with Colorectal Cancer

BACKGROUND/AIMS

The 5-year postoperative follow-up for patients undergoing curative treatment for colorectal cancer (CRC) is labour intensive. We assessed the added value of a dedicated nonphysician clinician (NPC) in the follow-up of patients after resection for CRC.

METHODS

Patients were divided into 2 groups as defined by the number of follow-up visits in the first year, including intensive (≥3×) and minimal (≤2×). Involvement of an NPC, diagnosis of disease recurrence and the course of the disease were determined.

RESULTS

Of the 681 patients, 79.9% belonged to the "intensive" and 21.1% to the "minimal" group. Involvement of an NPC resulted in a higher adherence to follow-up (84.3 vs. 73.9%, p = 0.001). Overall, patients in regular follow-up less often had multifocal recurrence (47.1 vs. 73.7%, p = 0.04), and a better survival after recurrence (SAR; hazard ratio [HR] 3.604, p < 0.001). The "intensive" group had a significantly better overall survival compared to the "minimal" group (HR 1.71, p = 0.013).

CONCLUSION

Adherence to surveillance programs after resection for CRC is better in hospitals with a dedicated NPC. Overall, patients' adherence to follow-up resulted in less multifocal disease recurrence at the time of diagnosis as compared to patients presenting with symptoms and a better 3-year SAR.

Advanced practice registered nurses, physician assistants and cancer prevention and screening: a systematic review

BACKGROUND

For more than two decades, integration of team-based approaches in primary care, including physicians, advanced practice registered nurses and physician assistants (APRN/PA), have been recommended for improving healthcare delivery, yet little is known about their roles in cancer screening and prevention. This study aims to review the current literature on the participation and roles of APRN/PAs in providing cancer screening and prevention recommendations in primary care settings in the United States.

METHODS

We searched MEDLINE and CINAHL to identify studies published in 1990-2011 reporting on cervical, breast, and colorectal cancer screening and smoking cessation, diet, and physical activity recommendations by APRN/PAs in the United States. A total of 15 studies met all of our eligibility criteria. Key study, provider, and patient characteristics were abstracted as were findings about APRN/PA recommendations for screening and prevention.

RESULTS

Most studies were cross-sectional, showed results from within a single city or state, had relatively small sample sizes, reported non-standardized outcome measures. Few studies reported any patient characteristics. APRN/PAs are involved in recommending cancer screening and prevention, although we found variation across screening tests and health behavior recommendations.

CONCLUSIONS

Additional research on the cancer prevention and screening practices of APRN/PAs in primary care settings using standardized outcome measures in relation to evidence-based guidelines may help strengthen primary care delivery in the United States.

Effectively Communicating Colorectal Cancer Screening Information to Primary Care Providers: Application for State, Tribe or Territory Comprehensive Cancer Control Coalitions

BACKGROUND

Patients are more likely to be screened for colorectal cancer if it is recommended by a health care provider. Therefore, it is imperative that providers have access to the latest screening guidelines.

PURPOSE

This practice-based project sought to identify Kentucky primary care providers' preferred sources and methods of receiving colorectal cancer information to improve state comprehensive cancer control provider outreach initiatives.

METHODS

Four focus groups were conducted with primary care physicians, nurse practitioners, and physician assistants. Discussion included preferred sources and methods of receiving updated screening guidelines, legislation, and statewide public awareness campaign materials.

RESULTS

Providers (N = 17) identified their preferred methods for receiving colorectal cancer information as: routine emails from trusted sources (colleagues, professional societies and research, and advocacy agencies), scientific journals, existing conferences, and the media.

DISCUSSION

When delivering colorectal cancer information to primary care providers, multiple approaches are needed. An ideal partner for dissemination of information is state comprehensive cancer control coalitions, considering their prioritization of colorectal cancer screening and existing networks of partners who were identified as trusted sources.

TRANSLATION TO HEALTH EDUCATION PRACTICE

Assessment of primary care providers' preferred methods and sources of receiving colorectal cancer information informs strategies for practice among comprehensive cancer control coalitions.

Knowledge and attitudes of primary health care physicians and nurses with regard to population screening for colorectal cancer in Balearic Islands and Barcelona

BACKGROUND

Primary health care (PHC) professionals play a key role in population screening of colorectal cancer. The purposes of the study are: to assess knowledge and attitudes among PHC professionals with regard to colorectal cancer screening, as well as the factors that determine their support for such screening.

METHODS

Questionnaire-based survey of PHC physicians and nurses in the Balearic Islands and in a part of the metropolitan area of Barcelona.

RESULTS

We collected 1,219 questionnaires. About 84% of all professionals believe that screening for colorectal cancer by fecal occult blood test (FOBT) is effective. Around 68% would recommend to their clients a colorectal cancer screening program based on FOBT and colonoscopy. About 31% are reluctant or do not know. Professionals perceive the fear of undergoing a colonoscopy as the main obstacle in getting patients to participate, and the invasive nature of this test is the main reason behind their resistance to this program. The main barriers to support the screening program among PHC professionals are lack of knowledge (nurses) and lack of time (physicians). On multivariate analysis, the factors associated with reluctance to recommend colorectal cancer screening were: believing that FOBT has poor sensitivity and is complicated; that colonoscopy is an invasive procedure; that a lack of perceived benefit could discourage client participation; that only a minority of clients would participate; thinking that clients are fed up with screening tests and being unaware if they should be offered something to ensure their participation in the programme.

CONCLUSIONS

Two in every three PHC professionals would support a population screening program for colorectal cancer screening. Factors associated with reluctance to recommend it were related with screening tests characteristics as sensitivity and complexity of FOBT, and also invasive feature of colonoscopy. Other factors were related with patients' believes.

Colorectal cancer screening practices among obstetrician/gynecologists and nurse practitioners

OBJECTIVE

Obstetrician/gynecologists (Ob/Gyn) and nurse practitioners (NP) are essential providers of primary and preventive care for their female patients. Therefore, colorectal cancer (CRC) screening should be part of their routine preventive practices. The purpose of our study is to evaluate the CRC screening practices of these providers.

METHODS

A self-administered survey was mailed to a national sample of 1130 Ob/Gyns and NPs to assess providers' demographics, current CRC screening practices, and familiarity with CRC guidelines.

RESULTS

Three hundred thirty-six providers (29.7%) returned our survey (54% Ob/Gyns and 46% NPs). Three fourths of providers routinely performed screening for CRC, compared with 95% for breast and cervical cancer. Routine CRC screening was more common among Ob/Gyns (87.2%) than NPs (61.7%) (p < 0.001). Slightly over half of providers correctly identified the recommended age to begin CRC screening for the average-risk patient, with no significant difference between provider types. Overall, Ob/Gyns scored higher than NPs on a series of questions assessing CRC screening (p < 0.03). Several provider factors were found to be significantly associated with screening practices, including practicing >10 years (p < 0.01), practicing in a multispecialty group (2.62 times more likely), and having an older patient population (p < 0.001).

CONCLUSIONS

Ob/Gyns and NPs underuse CRC screening compared with breast and cervical cancer screening and lack knowledge about appropriate use of CRC screening modalities. Opportunities to further educate Ob/Gyns and NPs should be sought to improve compliance with current CRC screening guidelines.

Nurses working in GI and endoscopic practice: a review

BACKGROUND

Over the last 10 years, nurses increasingly perform tasks and procedures that were previously performed by physicians.

OBJECTIVE

In this review, we investigated what types of GI care and endoscopic procedures nurses presently perform and reviewed the available evidence regarding the benefits of these activities.

DESIGN

Review of published articles on nurses' involvement in GI and endoscopic practice.

RESULTS

In total, 19 studies were identified that evaluated performance and participation of nurses in GI and endoscopic practice. Of these, 3 were randomized trials on the performance of nurses in flexible sigmoidoscopy (n = 2) and upper endoscopy (n = 1). Fourteen nonrandomized studies evaluated performance in upper endoscopy (n = 2), EUS (n = 1), flexible sigmoidoscopy (n = 7), capsule endoscopy (n = 2), and percutaneous endoscopic gastrostomy placement (n = 2). In all studies, it was found that nurses accurately and safely performed these procedures. Two further studies demonstrated that nurses adequately managed follow-up of patients with Barrett's esophagus and inflammatory bowel disease. Four of the 19 studies showed that patients were satisfied with the type of care nurses provided. Finally, it was suggested that costs were reduced if nurses performed a sigmoidoscopy and evaluated capsule endoscopy examinations compared with physicians performing these activities.

CONCLUSIONS

The findings of this review support the involvement of nurses in diagnostic endoscopy and follow-up of patients with chronic GI disorders. Further randomized trials, however, are needed to demonstrate whether this involvement compares at least as favorably with gastroenterologists in terms of medical outcomes, patient satisfaction, and costs.

Promoting culturally appropriate colorectal cancer screening through a health educator: a randomized controlled trial

BACKGROUND

Colorectal cancer (CRC) is a leading cause of cancer mortality in the US. Surveys reveal low CRC screening levels among Asians in the US, including Chinese Americans.

METHODS

A randomized controlled trial was conducted with Chinese patients to evaluate a clinic-based, culturally and linguistically appropriate intervention promoting fecal occult blood test (FOBT) screening. The multifaceted intervention included a trilingual and bicultural health educator, bilingual materials (a video, a motivational pamphlet, an informational pamphlet, and FOBT instructions), and three FOBT cards. Patients in the control arm received usual care. Our primary outcome measure was FOBT screening within 6 months after randomization. The proportion of FOBT completion in the intervention and control arms was compared by using a chi-square test, and logistic regression analysis was performed to adjust for the effects of sociodemographic variables and prior screening history. Potential effect modifications were also tested by using logistic regression models.

RESULTS

Our intervention had a strong effect on FOBT completion (intervention group, 69.5%; control group, 27.6%), and the adjusted odds of FOBT slightly increased to over 6-fold greater in the intervention arm compared with the control arm. No effect modification by age, gender, language, insurance, or prior FOBT was found.

CONCLUSIONS

The authors' multifaceted, culturally appropriate intervention significantly increased FOBT screening in a group of low-income and less-acculturated minority patients. Given the large effect size, future research should determine the effective core component(s) that can increase CRC screening in both the general and minority populations.

Collaborative colorectal cancer screening: a successful quality improvement initiative

PROBLEM

Low screening and referral rates for colorectal cancer at a primary care clinic suggest the need for alternative methods to identify patients and complete the screening process.

DESIGN

A review of >5000 medical charts established baseline screening and referral data. After a 3-month trial of a screening protocol, the research team conducted a follow-up medical chart review to determine referral levels.

BACKGROUND AND SETTING

The clinic is an 8-physician primary care facility in Southlake, Texas, and is one of 36 clinics affiliated with HealthTexas Provider Network.

KEY MEASURES FOR IMPROVEMENT

The goal was to increase referrals for colorectal cancer to at least 85% among patients aged 50 to 75 years.

STRATEGIES FOR IMPROVEMENT

The entire staff of the primary care clinic and the gastroenterology office became involved in the referral process. The team used simple tools such as chart stickers to draw attention to patients requiring screening, generation of referral forms that were numbered for follow-up and faxed to the gastroenterologists, and patient educational material on colorectal cancer screening. These tools were designed to overcome specific barriers to successful screening that the team had identified.

EFFECTS OF CHANGE

Referrals for sigmoidoscopy, colonoscopy, and double-contrast barium enema increased from 47% to 86%. Fecal occult blood testing was arranged for additional patients through the primary care office. Revenues related to colonoscopies increased by about 50% for the gastroenterologist group, the hospital, and the pathology group affiliated with Southlake Family Medicine.

LESSONS LEARNED

This colorectal cancer screening protocol succeeded in its 3-month trial because it was collaborative, opportunistic, simple, and made good business sense. The protocol is now being implemented at other HealthTexas Provider Network offices.

Physicians' use of nonphysician healthcare providers for colorectal cancer screening

BACKGROUND

Data on the involvement of nonphysician healthcare providers in colorectal cancer (CRC) screening delivery are sparse. This article describes physicians' use of nurse practitioners and physician assistants to provide CRC screening with the fecal occult blood test (FOBT), flexible sigmoidoscopy, and colonoscopy, as well as physicians' attitudes toward using these providers to perform flexible sigmoidoscopy.

METHODS

Nationally representative samples of primary care physicians, gastroenterologists, and general surgeons were surveyed in 1999-2000. Descriptive statistics and logistic regression were used to estimate the prevalence and predictors of physicians' use of nurse practitioners and physician assistants for CRC screening and to assess physicians' attitudes toward their use in providing CRC screening with flexible sigmoidoscopy.

RESULTS

Overall, 24% of primary care physicians reported using a nurse practitioner or physician assistant to provide CRC screening with FOBT. However, only 3% of all physicians surveyed used nurse practitioners and physician assistants for CRC screening with flexible sigmoidoscopy, and less than 1% of gastroenterologists and general surgeons reported using these providers to perform CRC screening with colonoscopy. Approximately 15% of general surgeons, 40% of primary care physicians, and 60% of gastroenterologists who do not currently use nurse practitioners or physician assistants to perform CRC screening with flexible sigmoidoscopy agreed that these providers could effectively perform the procedure.

CONCLUSIONS

These results show current involvement of nurse practitioners and physician assistants in the delivery of CRC screening to be limited. Use of nonphysician healthcare providers for CRC screening with FOBT and flexible sigmoidoscopy is one possible solution to the challenge of boosting low screening rates. However, physician beliefs about the ability of nurse practitioners and physician assistants to perform flexible sigmoidoscopy are a potential barrier to increasing the involvement of nonphysician providers in CRC screening delivery.

A national survey of primary care physicians' colorectal cancer screening recommendations and practices

BACKGROUND

National data on providers' colorectal cancer (CRC) screening knowledge, attitudes, and practices are sparse. This study assessed primary care physicians' (PCPs') beliefs about the effectiveness of CRC screening, their recommendations for screening, their perceptions of the influence of published guidelines on their CRC screening recommendations, and how they conduct CRC screening in their clinical practices.

METHODS

A questionnaire was administered to a nationally representative sample of practicing PCPs. Of 1718 eligible physicians, 1235 (72%) responded.

RESULTS

Only 2% of PCPs said they did not recommend CRC screening. Over 80% indicated that they most often recommend CRC screening with fecal occult blood testing and/or flexible sigmoidoscopy, although colonoscopy was perceived as the more effective screening modality. Nearly two-thirds of obstetrician/gynecologists and one-fourth of other practitioners reported conducting fecal occult blood testing exclusively by digital rectal exam. Only 29% of PCPs said they perform sigmoidoscopy. Estimated volumes of ordering, performing, or referring for CRC screening were low, and <20% reported that three-fourths or more of their older patients were up to date with CRC screening as recommended by the physician. Many PCPs reported recommending CRC screening at nonstandard starting ages or too-frequent intervals.

CONCLUSIONS

Awareness of CRC screening among PCPs in the United States is high. However, knowledge gaps about the timing and frequency of screening and suboptimal screening delivery were evident.