Colorectal cancer screening compliance by medicine residents: perceived and actual

Low Rate of Completion of Recommended Tests and Referrals in an Academic Primary Care Practice with Resident Trainees

BACKGROUND

A frequent, preventable cause of diagnostic errors involves failure to follow up on diagnostic tests, referrals, and symptoms-termed "failure to close the diagnostic loop." This is particularly challenging in a resident practice where one third of physicians graduate annually, and rates of patient loss due to these transitions may lead to more opportunities for failure to close diagnostic loops. The aim of this study was to determine the prevalence of failure of loop closure in a resident primary care clinic compared to rates in the faculty practice and identify factors contributing to failure.

METHODS

This retrospective cohort study included all patient visits from January 1, 2018, to December 31, 2021, at two academic medical center-based primary care practices where residents and faculty practice in the same setting. The primary outcome was prevalence of failure to close the loop for (1) dermatology referrals, (2) colonoscopy, and (3) cardiac stress testing. The primary predictor was resident vs. faculty status of the ordering provider. The authors present an unadjusted analysis and the results of a multivariable logistic regression analysis incorporating all patient factors to determine their association with loop closure.

RESULTS

Of 12,282 orders for referrals and tests for the three studied areas, 1,929 (15.7%) were ordered by a resident physician. Of resident orders for all three tests, 52.9% were completed within the designated time vs. 58.4% for orders placed by attending physicians (p < 0.01). In an unadjusted analysis by test type, a similar trend was seen for colonoscopy (51.4% completion rate for residents vs. 57.5% for attending physicians, p < 0.01) and for cardiac stress testing (55.7% completion rate for residents vs. 61.2% for attending physicians), though a difference was not seen for dermatology referrals (64.2% completion rate for residents vs. 63.7% for attending physicians). In an adjusted analysis, patients with resident orders were less likely than attendings to close the loop for all test types combined (odds ratio 0.88, 95% confidence interval 0.79-0.98), with low rates of test completion for both physician groups.

CONCLUSION

Loop closure for three diagnostic interventions was low for patients in both faculty and resident primary care clinics, with lower loop closure rates in resident clinics. Failure to close diagnostic loops presents a safety challenge in primary care and is of particular concern for training programs.

Breast Cancer Screening Practices in a Tertiary Care Center in the State of Qatar: A Cross-Sectional Survey

Introduction

Breast cancer is the most common cancer in females. In Qatar, mortality related to breast cancer came in third after lung cancer and leukemia. In this study, we aim to comprehensively evaluate the rate of internal medicine residents and faculty compliance with breast cancer screening in Hamad Medical Corporation (Doha, Qatar), as well as to identify barriers and facilitators that could potentially augment changes to enhance physician-led cancer screening.

Methods

A cross-sectional web-based survey was distributed among internal medicine physicians between December 2018 and March 2019 at a tertiary medical centre. It focused on the knowledge, attitude, and practice of physicians regarding breast cancer screening guidelines and explored potential barriers and proposed solutions. Chi-square and t-test statistics were used to draw conclusions where appropriate.

Results

A total of 158 physicians responded to the survey, with a response rate of 61%. 75.9% were postgraduate trainees. Around three-quarters of the physicians mentioned that they would recommend breast cancer screening for their age-appropriate average-risk patients. There was a statistically significant difference between the trainees, consultants, and specialists regarding the modality of choice, where the majority of the trainees opted mammogram every 2 or 3 years while 44.4% of the consultants indicated yearly self-breast exam (p<0.001). The percentage of survey participants who rarely to never offer breast cancer screening in the outpatient settings was 37.8%. Unclear pathway (40%) and lack of time in clinic/ward rounds (26.5%) were the major reported barriers for cancer screening.

Conclusion

In the current era of personalized medicine, physicians should be more oriented to local guidelines to provide optimal care to their patients. While the attitude towards breast cancer screening is positive, the overall compliance with the national recommendations is sub-optimal. Further initiatives and intervention programs are required to promote the breast cancer screening in Qatar.

Knowledge, Attitude and Practice of Physicians Regarding Screening of Colorectal Cancer in Qatar: A Cross-Sectional Survey

PURPOSE

The aim of this study was to evaluate the rate of internal medicine residents' and faculties' (specialists and consultants) compliance to colorectal cancer screening in Hamad Medical Corporation (Doha, Qatar) and to identify barriers as well as facilitators that will assist in drawing up changes that would enhance physician-related cancer screening.

METHODS

A cross-sectional web-based survey was distributed among internal medicine physicians at three component hospitals of Hamad Medical Corporation (HMC); focusing on knowledge and practice of colorectal cancer screening, its barriers and facilitators. Chi-square and t-test statistics were used to draw conclusions where appropriate.

RESULTS

The response rate for the survey was 91% and over 75% of the survey respondents were post-graduate trainees. The majority (90.6%) of the physicians (n=144) mentioned that they would recommend colorectal cancer screening for their asymptomatic patients, though trainees tend to choose the correct modality of screening compared to the consultants, 86.21% vs 40.74%. Only 43.4% of the survey participants always to usually recommend screening to their patients in their clinics while only 29.4% do so for their inpatients. Even though there was no statistically significant difference among the frequency of outpatient colorectal cancer screening among trainees, specialists or consultants (p=0.628), there was a clear increase in the reported referrals as the training years or the years of experience increases (p=0.049 for trainees and p=0.009 for faculty). Unclear pathway was reported as the main obstacle to outpatient cancer screening by 30.2% (n= 48) and 54% (n=87) pointed out that an easy and clear pathway for cancer screening would facilitate the same.

CONCLUSION

While the attitude towards colorectal cancer screening is positive, the actual practice of recommendation is sub-optimal. Further initiatives are required to facilitate awareness and compliance to colorectal cancer screening.

An Audit and Feedback Intervention to Improve Internal Medicine Residents' Performance on Ambulatory Quality Measures: A Randomized Controlled Trial

Audit and feedback is an effective method to improve attending physician performance. However, there are limited data on how audit and feedback impacts care provided by resident physicians. The authors conducted a 3-arm randomized clinical trial among internal medicine resident physicians to examine the impact of an audit and feedback intervention on ambulatory quality measures (AQMs). Residents in all 3 groups received an email containing the contact information of a population health coordinator and a list of AQMs (control). In addition, the Practice Target group received individual AQM data compared to the target AQM goals for all primary care practices. The Peer Comparison group received information on individual AQM data compared to the average performance of residents in the same postgraduate year. Residents in each intervention group received updated information 6 months later. Ten AQMs related to diabetes care, hypertension management, lipid control, and cancer screening, as well as a composite quality score, were examined at baseline, 6 months, and 13 months. At 13 months follow-up, the Practice Target group had statistically significant improvement in cervical cancer screening rate (77% vs. 65.3%), colorectal cancer screening rate (72.5% vs. 64.6%), and composite quality score (71.7% vs 65.4%) compared to baseline. Providing internal medicine residents with individual AQMs data compared to target goal for the practice led to statistically significant improvement in cancer screening rates and the composite quality score. Audit and feedback may be a relatively simple yet effective tool to improve population health in the resident clinic setting.

Policy of screening for colorectal cancer in Saudi Arabia: A prospective analysis

Colorectal cancer (CRC) is one of the most common cancers worldwide. Several policies of CRC screening are available in different countries. The idea of screening is to identify patients at risk by detection of precancerous and small cancers early enough before they become advanced. In Saudi Arabia (SA), there is no countrywide policy for CRC screening despite the increasing incidence of the disease. Screening for CRC is a multidisciplinary approach that requires education programs, substantial financial support, several logistic measures, and predetermined resources before implementing such a program. We performed a prospective and systematic analysis of the of the screening policy of CRC in SA in view of high demand, anticipated development, and implementation of such a policy in the near future. We also attempted to investigate the justification for developing such a policy, as well as the difficulties, barriers, and opportunities that may be faced in its implementation. Further, we highlighted the current view of similar international screening policies. In this analysis, we adopted the framework for health policy analysis that examines four areas which may affect policy development, namely; content, context, process and actors.

Knowledge of colorectal cancer screening among young Malaysians

The objective of this study was to determine the knowledge and associated factors regarding colorectal cancer screening among university students in Malaysia. The questionnaire consisted of three parts: socio-demographic characteristics, lifestyle practice and knowledge of colorectal screening. A cross-sectional study was conducted among 300 students (21.3±1.4 years old). The majority of the participants were Malay with a monthly family income of less than 5,000 Ringgit Malaysia (equal to 1,700 USD) (67.0% and 76.0%, respectively). Regarding their lifestyle practices, the majority were non-smokers and had never consumed alcohol (83.7%, and 88.0%, respectively). The majority of the participants had no knowledge of digital rectal examination, colonoscopy, barium enema and fecal occult blood screening (63.3%, 60.7%, 74.0% and 62.3%, respectively). Univariate and multivariate analysis revealed that their age and the discipline which the students were studying significantly influenced their level of knowledge about colorectal screening. The present study results indicate that education campaigns about colorectal cancer should be promoted.

Resident compliance with the american academy of ophthalmology preferred practice pattern guidelines for primary open-angle glaucoma

PURPOSE

To examine resident adherence to preferred practice pattern (PPP) guidelines set up by the American Academy of Ophthalmology for follow-up care of primary open-angle glaucoma (POAG) patients.

DESIGN

Retrospective chart review.

PARTICIPANTS

One hundred three charts were selected for analysis from all patients with an International Classification of Diseases, Ninth Revision, code of open-angle glaucoma or its related entities who underwent a follow-up evaluation between July 2, 2003, and December 15, 2004, at the resident ophthalmology clinic in the Durham Veteran Affairs Medical Center.

METHODS

Follow-up visits of POAG patients were evaluated for documentation of 19 elements in accordance to PPP guidelines.

MAIN OUTCOME MEASURES

Compliance rates for the 19 elements of PPP guidelines first were averaged in all charts, and then were averaged per resident and were compared among 8 residents between their first and second years of residency.

RESULTS

The overall mean compliance rate for all 19 elements was 82.6% for all charts (n = 103), 78.8% for first-year residents, and 81.7% for second-year residents. The increase from first to second year of residency was not significant (P>0.05). Documentation rates were high (>90%) for 14 elements, including all components of the physical examination and follow-up as well as most components of the examination history and management plan. Residents documented adjusting target intraocular pressure downward, local or systemic problems with medications, and impact of visual function on daily living approximately 50% to 80% of the time. Documentation rates for components of patient education were the lowest, between 5% and 16% in all charts.

CONCLUSIONS

Residents' compliance with PPP guidelines for a POAG follow-up visit was very high for most elements, but documentation rates for components of patient education were poor. Adherence rates to PPP guidelines can be used as a tool to evaluate and improve resident performance during training. However, further studies are needed to establish the advantages of using PPP guidelines for resident education and to determine if such assessments can lead to improved patient care.

Perceived colonoscopy barriers and facilitators among urban African American patients and their medical residents

African Americans suffer from higher colorectal cancer morbidity and mortality than do Whites, yet have the lowest screening rates. To understand barriers and facilitators to colorectal cancer screening, this study used perceptual mapping (multidimensional scaling) methods to compare patients' perceptions of colonoscopy and general preventive health practices to those of their doctors in a general internal medicine clinic in a large urban hospital. African American patients (n = 102) were surveyed about their own screening beliefs; third-year resident physicians (n = 29) were asked what they perceived their patients believed. The perceptual maps showed significant differences between the patients' and physicians' perceptions of barriers, facilitators, and beliefs about screening. Physicians believed logistical lifestyle issues were the greatest screening barriers for their patients whereas fears of complications, pain, and cancer were the most important barriers perceived by patients. Physicians also underestimated patients' understanding of the benefits and importance of screening, doctors' recommendations, and beliefs that faith in God could facilitate screening. Physicians and patients perceived a doctor's recommendation for screening was an important facilitator. Better understanding of patient perceptions can be used to improve doctor-patient communication and to improve medical resident training by incorporating specific messages tailored for use with African American patients.

Awareness and attitudes of Greek medical students on colorectal cancer screening

AIM: To prospectively assess the knowledge and attitudes of medical students (MS), as tomorrow’s physicians, about colorectal cancer (CRC) and its screening modalities.

METHODS: Three hundred fourth year MS of the University of Athens were enrolled in this survey. Their selection was random, based on student identification card number. All participants completed an anonymous written questionnaire over a 4 month period. The questionnaire was divided into 4 sections and included queries about CRC-related symptoms, screening with colonoscopy and MS awareness and attitudes in this field. Following collection and analysis of the data, the results are presented as percentages of answers for each separate question.

RESULTS: Two hundred and sixty-five students answered the questionnaire over a 4 mo period. Interestingly, only 69% of the study population considered CRC to be a high-risk condition for public health. However, the vast majority of participants identified CRC-related symptoms and acknowledged its screening to be of great value in reducing CRC incidence and mortality. A very small proportion (38%) had received information material regarding CRC screening (either during their medical training or as a part of information provided to the general public) and only 60% of the participants declared willingness to receive further information. Regarding colonoscopy, 85% would prefer an alternative to colonoscopy methods for CRC screening. Moreover, 53% considered it to be a painful method and 68% would appreciate more information about the examination.

CONCLUSION: MS in Greece need to be better informed about CRC screening and screening colonoscopy.

Clinical preventive services in Guatemala: a cross-sectional survey of internal medicine physicians

BACKGROUND

Guatemala is currently undergoing an epidemiologic transition. Preventive services are key to reducing the burden of non-communicable diseases, and smoking counseling and cessation are among the most cost-effective and wide-reaching strategies. Internal medicine physicians are fundamental to providing such services, and their knowledge is a cornerstone of non-communicable disease control.

METHODS

A national cross-sectional survey was conducted in 2011 to evaluate knowledge of clinical preventive services for non-communicable diseases. Interns, residents, and attending physicians of the internal medicine departments of all teaching hospitals in Guatemala completed a self-administered questionnaire. Participants' responses were contrasted with the Guatemalan Ministry of Health (MoH) prevention guidelines and the US Preventive Services Task Force (USPSTF) recommendations. Analysis compared knowledge of recommendations within and between hospitals.

RESULTS

In response to simulated patient scenarios, all services were recommended by more than half of physicians regardless of MoH or USPSTF recommendations. Prioritization was adequate according to the MoH guidelines but not including other potentially effective services (e.g. colorectal cancer and lipid disorder screenings). With the exception of colorectal and prostate cancer screening, less frequently recommended by interns, there was no difference in recommendation rates by level.

CONCLUSION

Guatemalan internal medicine physicians' knowledge on preventive services recommendations for non-communicable diseases is limited, and prioritization did not reflect cost-effectiveness. Based on these data we recommend that preventive medicine training be strengthened and development of evidence-based guidelines for low-middle income countries be a priority.

Natural language processing improves identification of colorectal cancer testing in the electronic medical record

BACKGROUND

Difficulty identifying patients in need of colorectal cancer (CRC) screening contributes to low screening rates.

OBJECTIVE

To use Electronic Health Record (EHR) data to identify patients with prior CRC testing.

DESIGN

A clinical natural language processing (NLP) system was modified to identify 4 CRC tests (colonoscopy, flexible sigmoidoscopy, fecal occult blood testing, and double contrast barium enema) within electronic clinical documentation. Text phrases in clinical notes referencing CRC tests were interpreted by the system to determine whether testing was planned or completed and to estimate the date of completed tests.

SETTING

Large academic medical center.

PATIENTS

200 patients ≥ 50 years old who had completed ≥ 2 non-acute primary care visits within a 1-year period.

MEASURES

Recall and precision of the NLP system, billing records, and human chart review were compared to a reference standard of human review of all available information sources.

RESULTS

For identification of all CRC tests, recall and precision were as follows: NLP system (recall 93%, precision 94%), chart review (74%, 98%), and billing records review (44%, 83%). Recall and precision for identification of patients in need of screening were: NLP system (recall 95%, precision 88%), chart review (99%, 82%), and billing records (99%, 67%).

LIMITATIONS

Small sample size and requirement for a robust EHR.

CONCLUSIONS

Applying NLP to EHR records detected more CRC tests than either manual chart review or billing records review alone. NLP had better precision but marginally lower recall to identify patients who were due for CRC screening than billing record review.

Process evaluation of recruitment for a cancer screening trial in primary care

Many cancer screening studies are conducted in primary care settings, yet few systematically analyze recruitment challenges found at these sites. During a randomized trial promoting colorectal cancer screening, we implemented a process evaluation of recruitment. Recruiters maintained logs that registered the numbers of patients entering the clinic, approached by recruiters, declining to participate, and reasons for nonapproach and nonparticipation. One half of age-eligible patients were approached (n = 1,489), and half of those who met basic eligibility requirements agreed to engage further (n = 527). A small proportion of patients (n = 98) completed the 15-min assessment before their appointment. Major reasons for nonapproach included previous approach, patients called to the exam room, and appearing ill. The major reason for nonparticipation was "not interested"; a few patients did not want to share contact information. Some participants exited the assessment midway because of further ineligibility or time limitations. Best-practice recommendations for recruitment in primary care are discussed.

Knowledge and attitudes regarding colorectal cancer screening among medical students: a tale of two schools

Colorectal cancer (CRC) screening has been shown to decrease the incidence of CRC cancers and decrease mortality. Studies show that the most important predictor of patient compliance with CRC screening is physician recommendation. We assessed the knowledge and attitudes of medical students regarding cancer screening. A study-specific questionnaire was distributed to medical students (MS) at two medical schools. There was a significant difference in the percentage of correctly answered questions regarding screening recommendations between first year MS and all other years for both schools. However, MS attitudes towards CRC screening were consistent between classes and schools. Although most MS had positive attitudes regarding cancer screening our survey identified several important deficits in knowledge.

Knowledge about cancer screening among medical students and internal medicine residents in Mexico City

It is extremely important that physicians are aware of cancer screening precise indications. We sought to explore its knowledge among Mexican medical students and internal medicine residents. Students and residents completed a questionnaire-based survey about breast, cervical, colon, and prostate cancer screening. Four hundred fifty-one individuals answered the survey: 64.52% students and 35.48% residents. Mean knowledge score was 63.97 ± 14.97. Residents scored higher than students (p = 0.0001). No difference in the education concerning cervical and colon cancer screening was found. Knowledge of screening guidelines is suboptimal among medical students and residents. Further efforts should be targeted to educational and training programs in this country.

Get screened: a pragmatic randomized controlled trial to increase mammography and colorectal cancer screening in a large, safety net practice

Background

Most randomized controlled trials of interventions designed to promote cancer screening, particularly those targeting poor and minority patients, enroll selected patients. Relatively little is known about the benefits of these interventions among unselected patients.

Methods/Design

"Get Screened" is an American Cancer Society-sponsored randomized controlled trial designed to promote mammography and colorectal cancer screening in a primary care practice serving low-income patients. Eligible patients who are past due for mammography or colorectal cancer screening are entered into a tracking registry and randomly assigned to early or delayed intervention. This 6-month intervention is multimodal, involving patient prompts, clinician prompts, and outreach. At the time of the patient visit, eligible patients receive a low-literacy patient education tool. At the same time, clinicians receive a prompt to remind them to order the test and, when appropriate, a tool designed to simplify colorectal cancer screening decision-making. Patient outreach consists of personalized letters, automated telephone reminders, assistance with scheduling, and linkage of uninsured patients to the local National Breast and Cervical Cancer Early Detection program. Interventions are repeated for patients who fail to respond to early interventions. We will compare rates of screening between randomized groups, as well as planned secondary analyses of minority patients and uninsured patients. Data from the pilot phase show that this multimodal intervention triples rates of cancer screening (adjusted odds ratio 3.63; 95% CI 2.35 - 5.61).

Discussion

This study protocol is designed to assess a multimodal approach to promotion of breast and colorectal cancer screening among underserved patients. We hypothesize that a multimodal approach will significantly improve cancer screening rates.

The trial was registered at Clinical Trials.gov NCT00818857

Barriers of and facilitators to physician recommendation of colorectal cancer screening

BACKGROUND

Colorectal cancer screening (CRCS) has been demonstrated to be effective and is consistently recommended by clinical practice guidelines. However, only slightly over half of all Americans have ever been screened. Patients cite physician recommendation as the most important motivator of screening. This study explored the barriers of and facilitators to physician recommendation of CRCS.

METHODS

A 3-component qualitative study to explore the barriers of and facilitators to physician recommendation of CRCS: in-depth, semistructured interviews with 29 purposively sampled, community- and academic-based primary care physicians; chart-stimulated recall, a technique that utilizes patient charts to probe physician recall and provide context about the barriers of and facilitators to physician recommendation of CRCS during actual clinic encounters; and focus groups with 18 academic primary care physicians. Grounded theory techniques of analysis were used.

RESULTS

All the participating physicians were aware of and recommended CRCS. The overwhelmingly preferred test was colonoscopy. Barriers of physician recommendation of CRCS included patient comorbidities, prior patient refusal of screening, physician forgetfulness, acute care visits, lack of time, and lack of reminder systems and test tracking systems. Facilitators to physician recommendation of CRCS included patient request, patient age 50-59, physician positive attitudes about CRCS, physician prioritization of screening, visits devoted to preventive health, reminders, and incentives.

CONCLUSION

There are multiple physician, patient, and system barriers to recommending CRCS. Thus, interventions may need to target barriers at multiple levels to successfully increase physician recommendation of CRCS.

Colorectal cancer screening education, prioritization, and self-perceived preparedness among primary care residents: data from a national survey

BACKGROUND

Colorectal cancer (CRC) screening remains underutilized in the United States. We conducted a national survey of CRC screening education, prioritization, and self-perceived preparedness among resident physicians in Family Practice (FP), Internal Medicine (IM), and Obstetrics and Gynecology (OB/GYN) training programs.

METHODS

Directors/administrators from 1085 FP, IM, and OB/GYN training programs were contacted by e-mail with a request to forward an invitation to participate in our Web-based CRC screening education survey to all residents in their program. Willing residents submitted responses in anonymous fashion. Data were analyzed using chi2 tests and analysis of variance methods.

RESULTS

In total, 243 program directors/administrators forwarded our invitation, and 835 residents responded (384 FP, 266 IM, 177 OB/GYN, 8 undesignated specialty). Nearly all resident responders (89%) had received CRC screening education, but few content delivery methods were reported. Most felt at least somewhat comfortable or somewhat knowledgeable with respect to advising patients about CRC screening (90%), currently endorsed CRC screening guidelines (89%), and criteria used to identify familial CRC syndromes (50%). However, substantially fewer respondents reported feeling very comfortable or very knowledgeable in these areas (45%, 23%, and 5%, respectively). Program specialty, level of training, and gender were the strongest indicators of self-perceived preparedness.

CONCLUSIONS

Although based on a relatively small sample of all FP, IM, and OB/GYN residents, these data suggest tangible opportunities to improve the CRC screening curriculum in primary care residency programs.

Colorectal cancer screening: physicians' knowledge of risk assessment and guidelines, practice, and description of barriers and facilitators

BACKGROUND

Physician nonadherence to colorectal cancer (CRC) screening recommendations contributes to underuse of screening.

OBJECTIVE

To assess physicians' knowledge of CRC screening guidelines for average-risk individuals, perceived barriers to screening and practice behaviours.

METHODS

Between October 2004 and March 2005, staff physicians working in three university-affiliated hospitals in Montreal, Quebec, were surveyed. Self-administered questionnaires assessed knowledge of risk classification and current guidelines for average-risk individuals, as well as perceptions of barriers to screening and practice behaviours.

RESULTS

All 65 invited physicians participated in the survey, including 46 (70.8%) family medicine physicians and 19 (29.2%) general internists. Most physicians knew that screening should begin at 50 years of age, all knew to screen men and women and 92% said they screened average-risk patients. Fifty-seven (87.7%) physicians correctly identified three common characteristics associated with high risk for developing CRC. Physicians who screened average-risk patients preferred fecal occult blood testing (88.3%) and colonoscopy (88.3%) to flexible sigmoidoscopy (10.0%) and double-contrast barium enema (30.0%). Most physicians knew the correct screening periodicity for fecal occult blood testing (87.6%), but only 40% or fewer could identify correct screening periodicities for the other modalities. Barriers and facilitators focused on health care delivery system improvements, better evidence on which to base recommendations and development of practical screening modalities.

CONCLUSIONS

Physicians lacked knowledge of the recommended screening modalities and periodicities to appropriately screen average-risk individuals. Because CRC screening can reduce mortality, efforts to improve physician delivery should focus on physician knowledge and changes to the health care delivery system.

Colorectal cancer screening: health impact and cost effectiveness

BACKGROUND

Colorectal cancer is the second leading cause of cancer-related death in the United States, yet recommended screenings are not delivered to most people. This assessment of colorectal cancer screening's value to the U.S. population is part of the update to a 2001 ranking of recommended clinical preventive services found in the accompanying article. This article describes the burden of disease prevented and cost-effectiveness as a result of offering patients a choice of colorectal cancer screening tools.

METHODS

Methods used were designed to ensure consistent estimates across many services and are described in more detail in the companion articles. In a secondary analysis, the authors also estimated the impact of increasing offers for colorectal cancer screening above current levels among the current cross-section of adults aged 50 and older.

RESULTS

If a birth cohort of 4 million were offered screening at recommended intervals, 31,500 deaths would be prevented and 338,000 years of life would be gained over the lifetime of the birth cohort. In the current cross-section of people aged 50 and older, 18,800 deaths could be prevented each year by offering all people in this group screening at recommended intervals. Only 58% of these deaths are currently being prevented. In year 2000 dollars, the cost effectiveness of offering patients aged 50 and older a choice of colorectal cancer screening options is $11,900 per year of life gained.

CONCLUSIONS

Colorectal cancer screening is a high-impact, cost-effective service used by less than half of persons aged 50 and older.

Risk stratification of colon carcinogenesis through enhanced backscattering spectroscopy analysis of the uninvolved colonic mucosa

INTRODUCTION

Our group has been interested in applying advances in biomedical optics to colorectal cancer risk stratification. Through a recent technological breakthrough, we have been able to harness information from enhanced backscattering spectroscopy, an optics phenomenon that allows quantitative, depth-selective analysis of the epithelial microscale/nanoscale architecture. In the present study, we investigated the ability of enhanced backscattering analysis of the preneoplastic mucosa to predict risk of colon carcinogenesis.

METHODS

Enhanced backscattering analysis was done on intestinal mucosa at preneoplastic time points from two experimental models of colorectal cancer: the azoxymethane-treated rat and the multiple intestinal neoplasia (MIN) mouse. Data were analyzed using two previously validated spectral markers: spectral slope and principle components. We then did a pilot study on mucosal biopsies from 63 subjects undergoing screening colonoscopy.

RESULTS

In the azoxymethane-treated rat, when compared with saline-treated controls, significant changes in the enhanced backscattering markers were observed as early as 2 weeks after azoxymethane treatment (before the development of aberrant crypt foci and adenomas). Enhanced backscattering markers continued to progress over time in a manner consonant with future neoplasia. These data were replicated in the preneoplastic MIN mouse mucosa. In humans, spectral slopes in the endoscopically normal cecum, midtransverse colon, and rectum were markedly reduced in patients harboring adenomas when compared with those who were neoplasia free.

CONCLUSIONS

We show, for the first time, that enhanced backscattering analysis of an aliquot of uninvolved mucosa has the potential for predicting neoplastic risk throughout the colon in both experimental colorectal cancer models and humans.

Physician and patient influences on the rate of colorectal cancer screening in a primary care clinic

BACKGROUND

Colorectal cancer (CRC) screening rates remain low, despite widespread recommendations. The study purpose was to ascertain whether lack of CRC screening is attributable to physicians' failure to address CRC screening or to patients' failure to comply with physician recommendation. This relationship was also examined over time.

METHODS

Retrospective chart review of 400 preventive health visits.

RESULTS

Physicians appropriately addressed screening 16.5% of the time during 1998-1999 and 51% of the time during 2002-2003 (P <or= .001). The rate of test completion by patients was 53% in 1998-1999 and 31% in 2002-2003, resulting in completed CRC screening rates of 5% and 16.5%, respectively (P <or= .001).

CONCLUSIONS

Further education is needed, especially to target patient barriers to CRC screening test completion.

Changing habits of practice. Transforming internal medicine residency education in ambulatory settings

PURPOSE

The majority of health care, both for acute and chronic conditions, is delivered in the ambulatory setting. Despite repeated proposals for change, the majority of internal medicine residency training still occurs in the inpatient setting. Substantial changes in ambulatory education are needed to correct the current imbalance. To assist educators and policy makers in this process, this paper reviews the literature on ambulatory education and makes recommendations for change.

METHODS

The authors searched the Medline, Psychlit, and ERIC databases from 2000 to 2004 for studies that focused specifically on curriculum, teaching, and evaluation of internal medicine residents in the ambulatory setting to update previous reviews. Studies had to contain primary data and were reviewed for methodological rigor and relevance.

RESULTS

Fifty-five studies met criteria for review. Thirty-five of the studies focused on specific curricular areas and 11 on ambulatory teaching methods. Five involved evaluating performance and 4 focused on structural issues. No study evaluated the overall effectiveness of ambulatory training or investigated the effects of current resident continuity clinic microsystems on education.

CONCLUSION

This updated review continues to identify key deficiencies in ambulatory training curriculum and faculty skills. The authors make several recommendations: (1) Make training in the ambulatory setting a priority. (2) Address systems problems in practice environments. (3) Create learning experiences appropriate to the resident's level of development. (4) Teach and evaluate in the examination room. (5) Expand subspecialty-based training to the ambulatory setting. (6) Make faculty development a priority. (7) Create and fund multiinstitutional educational research consortia.

Computer-aided detection (CAD) for CT colonography: a tool to address a growing need

Colorectal cancer is the third most common cancer in both men and women. It is estimated that in 2004, nearly 147,000 cases of colon and rectal cancer will be diagnosed in the USA, and approximately 57,000 people would die from the disease; however, only 44% of the eligible population undergoes any type of colorectal cancer screening. Many reasons have been identified for non-compliance, with key ones being patient comfort, bowel preparation and cost. Virtual colonoscopy derived from computed tomography (CT) images is gaining broader acceptance as a screening method for colorectal neoplasia. Our research suggests that computer-aided detection (CAD) as a second reader has great potential in improving polyp detection. The ColonCAD prototype presented in this paper was developed and tested on cases representative of the variability and quality in true clinical practice. Results of this study with 150 patients demonstrate that: the developed algorithm generalises well: the sensitivity for polyps > or = 6 mm is on average 90%; and the median false positive rate is a manageable 3 per volume.

The difference between study recommendations, stated policy, and actual practice in a clinical trial

BACKGROUND

We determined whether physicians involved in a clinical trial adhere to the study recommendations or the stated policy of their treatment centre with respect to the administration of boost radiation after breast conserving surgery.

PATIENTS AND METHODS

Boost radiation treatment policy was determined by survey at 25 oncology centres involved in a randomised trial of breast or breast plus nodal radiation in Canada. Actual practice was compared with stated policy and study recommendations.

RESULTS

Among 248 subjects, 201 (81%) were treated according to stated policy [kappa=0.40, 95% confidence intervals (CI) 0.27-0.52; P<0.0001], indicating only a fair to moderate agreement between stated and actual practice, while 232 (94%) were treated according to study recommendations (kappa=0.59, 95% CI 0.40-0.77; P<0.0001), indicating moderate to near substantial agreement between study recommendations and actual practice (P=0.88 for z-test of difference). In a multivariate analysis, subjects who had invasive disease at a resection margin were more likely to get a boost than those with margins clear of invasive tumour by 2 mm [odds ratio (OR) 49, 95% CI 7.6-322; P<0.0001].

CONCLUSIONS

Physicians appear compliant with study recommendations for a non-randomised manoeuvre in a clinical trial, possibly at the expense of compliance with stated local policy. Clinical trial protocols should incorporate standard practice.

Prevalence of colorectal cancer screening in a large medical organization

The primary objective of this study was to determine the prevalence of colorectal cancer (CRC) screening among eligible patients in a large medical practice. A secondary objective was to compare CRC screening rates obtained from medical records with physician self-reported CRC screening recommendation. We conducted a retrospective record review of 214 patients ages > or = 50 years of a large multispecialty medical organization in Houston, Texas, for receipt of fecal occult blood test (FOBT), flexible sigmoidoscopy (SIG), and/or colonoscopy (COL). We estimated prevalence using two definitions: (a) FOBT in past year or SIG in past 5 years or COL in past 10 years; and (b) FOBT in past year and SIG in past 5 years or COL in past 10 years. Age, gender, race/ethnicity, family history, number of chronic conditions, and index visit were independent variables. Contingency table and logistic regression analysis were used to test for associations between outcomes and independent variables. Our study population was 48% male with a mean age of 63 years (range: 53-84 years). One-quarter of the records showed FOBT by 3-day kit (51 of 214) and 27% by digital rectal exam (57 of 214). SIG was recorded in 32% of records. Half (54%) of the records had documentation of CRC screening according to definition no. 1 and 19% according to definition no. 2. Screening rates from medical record review were lower than those derived from physician self-report. Our findings underscore the need for interventions to improve CRC screening in primary care settings.

Barriers to colorectal cancer screening: an educational diagnosis

BACKGROUND

Colorectal cancer (CRC) is a largely preventable disease through early detection and treatment, yet screening rates remain low and mortality rates remain high, particularly among low-income, minority populations. This study was conducted to identify barriers to CRC screening.

METHODS

Repeated telephone contacts were conducted with 226 individuals from 52 to 80 years of age, who had not recently received CRC screening. The contacts were intended to educate and encourage participants to obtain CRC screening. Within this context, CRC screening barriers were identified and categorized using an educational diagnosis as specified in the Precede-Proceed Framework.

RESULTS

Findings showed that the most frequently observed barrier was lack of familiarity with CRC screening guidelines and tests. Availability and accessibility to screening tests was a barrier that was difficult to overcome for many participants. The majority of participants faced two or more barriers.

CONCLUSIONS

This study suggests a need for public health education about CRC screening guidelines and tests and greater accessibility to CRC screening.

Colorectal cancer screening and familial risk: a survey of internal medicine residents' knowledge and practice patterns

OBJECTIVE

Risk stratification is essential to the appropriate use of colorectal cancer screening recommendations. The principal objective of this study was to assess the knowledge and screening behavior of internal medicine (IM) residents regarding familial colorectal cancer.

METHODS

We conducted a survey of IM residents in their second and third year of postgraduate training from two university-based programs (n = 127). The survey instrument assessed physician knowledge of screening recommendations and current practices for individuals with a family history of colorectal cancer, adenomatous polyps, familial adenomatous polyposis, and hereditary nonpolyposis colorectal cancer. The instrument also elicited data regarding familial risk assessment, documentation, and notification of at-risk family members.

RESULTS

Eighty-one IM eligible residents (81%) completed the survey. Most respondents identified a family history of colorectal cancer as an important factor in assessing colorectal cancer risk and appropriately implemented relevant screening recommendations. However, for patients with a family history of adenomatous polyps diagnosed before age 60 yr, knowledge and adherence to recommendations advocating screening at age 40 was relatively poor. More importantly, for patients with familial adenomatous polyposis and hereditary nonpolyposis colorectal cancer, respondents lacked the necessary risk assessment skills and knowledge to appropriately implement current recommendations. There were no consistent differences in knowledge or screening behavior when stratified on the basis of program site or postgraduate year status.

CONCLUSION

Many IM residents are deficient in their knowledge, risk assessment skills, and screening practices for patients at familial risk of colorectal cancer. Effective educational strategies that promote awareness regarding familial risk, risk assessment skills, and appropriate use of relevant screening guidelines are needed.

Achieving utility with family history: colorectal cancer risk

Family history of chronic disease is rapidly becoming a research tool for targeting participants at increased risk. Its current usefulness in clinical practice remains unknown. This paper details the possible utility and complications in using family history in a primary care setting, using colorectal cancer risk as the health issue. Where available, we cite data to support the issues that could arise. Where there are no studies, we invite further research. The potential of family history as a health improvement tool is still under review.

Colon cancer screening strategies

Screening has been shown to reduce morbidity and mortality related to colorectal cancer. However, the optimal strategy for population screening for colorectal cancer has been a topic of heated debate. Recent studies have challenged the efficacy and cost-effectiveness of current population screening practices. Novel approaches to improve the assessment of an individual's colorectal cancer risk and advances in technology are changing our approach to colorectal screening. This review covers current guidelines for screening for colorectal cancer, recent advances in cancer risk assessment, and the role of endoscopy, virtual colonoscopy, and fecal DNA testing in colorectal cancer screening.