Physicians' colorectal cancer screening discussion and recommendation patterns

Effectiveness and implementation of mPATH™-CRC: a mobile health system for colorectal cancer screening

BACKGROUND

Screening for colorectal cancer (CRC) is widely recommended but underused, even though CRC is the third most diagnosed cancer and the second leading cause of cancer death in the USA. The mPATH™ program is an iPad-based application designed to identify patients due for CRC screening, educate them on the commonly used screening tests, and help them select their best option, with the goal of increasing CRC screening rates.

METHODS

The mPATH™ program consists of questions asked of all adult patients at check-in (mPATH™-CheckIn), as well as a module specific for patients due for CRC screening (mPATH™-CRC). In this study, the mPATH™ program is evaluated through a Type III hybrid implementation-effectiveness design. Specifically, the study consists of three parts: (1) a cluster-randomized controlled trial of primary care clinics comparing a "high touch" evidence-based implementation strategy with a "low touch" implementation strategy; (2) a nested pragmatic study evaluating the effectiveness of mPATH-CRC™ on completion of CRC screening; and (3) a mixed-methods study evaluating factors that facilitate or impede the maintenance of interventions like mPATH-CRC™. The primary objective is to compare the proportion of patients aged 50-74 who are eligible for CRC screening who complete mPATH™-CRC in the 6th month following implementation between the "high touch" and "low touch" implementation strategies. Effectiveness of mPATH™-CRC is evaluated by comparing the proportion who complete CRC screening within 16 weeks of their visit to the clinic between a pre-implementation cohort (8 months before implementation) and a post-implementation cohort (8 months after implementation).

DISCUSSION

This study will provide data on both the implementation of the mPATH™ program and its effectiveness in improving screening rates for CRC. In addition, this work has the potential to have an even broader impact by identifying strategies to support the sustained use of other similar technology-based primary care interventions.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03843957. Registered on 18 February 2019.

Awareness and knowledge of Colorectal Cancer Screening among Latinos in Omaha, Nebraska

BACKGROUND

Colorectal cancer (CRC) screening rates remain low in Latino communities. We sought to determine the screening awareness and attitudes in Omaha, Nebraska.

METHODS

We interviewed 150 Latinos at an urban Federally Qualified Health Center, June-October 2017. Chi-square or Fisher-exact tests and multiple logistic regression models were used for data analysis.

RESULTS

Participants reported low educational attainment, low income, and limited access to insurance or a primary provider. Less than one-third of participants aged 50 + had ever heard of FOBT (32.6%) or colonoscopy (30.4%). For individuals 50+, access to a primary care provider (p = .03) and knowing the screening initiation age (p = .03) were associated with ever having a colonoscopy. Higher knowledge score was a strong predictor of any CRC screening.

DISCUSSION

Knowledge predicted screening, suggesting interventions should aim to educate this population regarding CRC screening guidelines and options and work with stakeholders to make CRC screening more accessible.

Fecal immunochemical test (FIT) versus colonoscopy: Does knowing that a positive FIT requires a follow-up colonoscopy affect initial decision making in the US?

Although many people prefer fecal immunochemical test (FIT) over colonoscopy due to its noninvasive nature, it is unclear whether FIT would still be preferred for colorectal cancer (CRC) screening if they were explicitly informed that + FIT requires follow-up colonoscopy. To address this gap, we administered two conjoint analysis surveys-one that explained the need for a follow-up colonoscopy after + FIT while the other did not-to a US nationwide sample of Americans and then assessed whether there were differences in colonoscopy/FIT preferences between cohorts. We recruited adults ≥ 40yo who had not undergone CRC screening via an online survey research firm. We deployed two surveys that used conjoint analysis to assess decision making surrounding CRC screening tests: Survey 1 (4/2-4/15/2021)-did not inform participants that they need a colonoscopy following a + FIT; Survey 2 (4/29-6/2/2021)-informed respondents of the potential need. Using the conjoint analysis data, we determined the proportion of those who preferred FIT or colonoscopy and then used logistic regression to assess for differences in colonoscopy/FIT preferences between the cohorts. Overall, 501 and 1,000 individuals completed Survey 1 (without description of need for colonoscopy after + FIT) and Survey 2 (with description), respectively. There was no difference in test preference between cohorts after adjusting for covariates in the logistic regression (adjusted p = 0.09): Survey 1 (without description)-colonoscopy 28.5%, FIT 71.5%; Survey 2 (with description)-colonoscopy 26.7%, FIT 73.3%. Thus, knowledge that a + FIT requires a follow-up colonoscopy does not alter people's strong preference for non-invasive stool testing with FIT.

Disparities in Colorectal Cancer Screening Practices in a Midwest Urban Safety-Net Healthcare System

AIMS

Although colorectal cancer screening (CRC) using stool-based test is well-studied, evidence on fecal immunochemical test (FIT) patterns in a safety-net healthcare system utilizing opportunistic screening is limited. We studied the FIT completion rates and adenoma detection rate (ADR) of positive FIT-colonoscopy (FIT-C) in an urban safety-net system.

METHODS

We performed a retrospective cross-sectional chart review on individuals ≥ 50 years who underwent CRC screening using FIT or screening colonoscopy, 09/01/2017-08/30/2018. Demographic differences in FIT completion were studied; ADR of FIT-C was compared to that of screening colonoscopy.

RESULTS

Among 13,427 individuals with FIT ordered, 7248 (54%) completed the stool test and 230 (48%) followed up a positive FIT with colonoscopy. Increasing age (OR 1.01, CI 1.01-1.02), non-Hispanic Blacks (OR 0.87, CI 0.80-0.95, p = 0.002), current smokers (OR 0.84, CI 0.77-0.92, p < 0.0001), those with Medicaid (OR 0.86, CI 0.77-0.96, p = 0.006), commercial insurance (OR 0.85, CI 0.78-0.94, p = 0.002), CCI score ≥ 3 (OR 0.82, CI 0.74-0.91, p < 0.0001), orders by family medicine providers (OR 0.87, CI 0.81-0.94, p < 0.0001) were associated with lower completion of stool test. Individuals from low median household income cities had lower follow-up of positive FIT, OR 0.43, CI 0.21-0.86, p = 0.017. ADR of FIT-C was higher than that of screening colonoscopy.

CONCLUSION

Adherence to CRC screening is low in safety-net systems employing opportunistic screening. Understanding demographic differences may allow providers to formulate targeted strategies in high-risk vulnerable groups.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Implementing a multilevel intervention to accelerate colorectal cancer screening and follow-up in federally qualified health centers using a stepped wedge design: a study protocol

Background

Screening for colorectal cancer (CRC) not only detects disease early when treatment is more effective but also prevents cancer by finding and removing precancerous polyps. Because many of our nation’s most disadvantaged and vulnerable individuals obtain health care at federally qualified health centers, these centers play a significant role in increasing CRC screening among the most vulnerable populations. Furthermore, the full benefits of cancer screenings must include timely and appropriate follow-up of abnormal results. Thus, the purpose of this study is to implement a multilevel intervention to increase rates of CRC screening, follow-up, and referral-to-care in federally qualified health centers, as well as simultaneously to observe and to gather information on the implementation process to improve the adoption, implementation, and sustainment of the intervention. The multilevel intervention will target three different levels of influences: organization, provider, and individual. It will have multiple components, including provider and staff education, provider reminder, provider assessment and feedback, patient reminder, and patient navigation.

Methods

This study is a multilevel, three-phase, stepped wedge cluster randomized trial with four clusters of clinics from four different FQHC systems. In the first phase, there will be a 3-month waiting period during which no intervention components will be implemented. After the 3-month waiting period, we will randomize two clusters to cross from the control to the intervention and the remaining two clusters to follow 3 months later. All clusters will stay at the same phase for 9 months, followed by a 3-month transition period, and then cross over to the next phase.

Discussion

There is a pressing need to reduce disparities in CRC outcomes, especially among racial/ethnic minority populations and among populations who live in poverty. Single-level interventions are often insufficient to lead to sustainable changes. Multilevel interventions, which target two or more levels of changes, are needed to address multilevel contextual influences simultaneously. Multilevel interventions with multiple components will affect not only the desired outcomes but also each other. How to take advantage of multilevel interventions and how to implement such interventions and evaluate their effectiveness are the ultimate goals of this study.

Trial registration

This protocol is registered at clinicaltrials.gov (NCT04514341) on 14 August 2020.

Breast Cancer Screening Practices for High-Risk Women: A Cross-Sectional Survey of Primary Care Providers

Background: Little literature exists on primary care providers' knowledge and preferences toward breast cancer screening for high-risk women. Materials and Methods: A cross-sectional web-based survey of primary care providers in Minnesota was conducted in 2016. The primary aim was to determine the breast cancer screening practices of primary care providers for women at high risk for breast cancer. A multipart questionnaire focused on breast cancer screening practices for high-risk women and perceived risks/benefits of breast cancer screening was administered. Statistical analyses, included descriptive statistics and tests of differences in screening practices and knowledge across key professional characteristics, were conducted. Results: Eight hundred five primary care providers completed the survey (7.7% response). Participants were predominantly female (72.2%); 43.9% were physicians, 11.4% physician assistants, and 44.8% advanced practice registered nurses. One-quarter of providers recommended mammography and breast magnetic resonance imaging (MRI) for high-risk women ages 40-49 years. There were no differences in breast MRI recommendations based on years of experience or practice setting. In high-risk women with prior chest radiation and an increased risk of breast cancer, for whom guidelines recommend mammography and MRI, 75.0% of providers recommended mammography, but only 44.3% recommended breast MRI. Recent continuing education on breast cancer screening was associated with providers being more comfortable giving high-risk screening recommendations (p = 0.002). Conclusions: Most primary care providers believe mammography is helpful in women at high risk for breast cancer. Less than half of practitioners, however, recommend breast MRI to screen women at high risk for breast cancer, despite guidelines promoting the use of breast MRI. Increased provider education is warranted.

Implementing Colon Cancer Screening Guidelines Into the Primary Care Setting

Colon cancer is the second leading cause of all cancers deaths. Despite public awareness, many healthcare providers and patients remain uninformed about colon cancer screening options alternative to colonoscopy. Research supports the lack of providers' education and patient knowledge. At a clinic for veterans in Central Florida, 2 educational presentations were delivered to primary care providers (N = 46) on the clinical pathway for colon cancer screening options. A pilot study with a quantitative pretest-post-test design was used to evaluate differences between screening orders 3 months before and after the presentations. A 10-item survey on the usefulness of the educational information was also administered to providers. Results of a 1-way analysis of variance indicated no significant differences between the two 3-month periods. However, with exclusion of the lowest month, a significance level resulted of .087, 91.3% confidence level. Survey responses indicated a positive impact, with most answers ranging from agree to strongly agree. The study revealed that the educational clinical pathway contributed to providers' increased recommendations of screening options and the educational information was useful. Additional research is recommended on the effectiveness of education and providers' use of screening options for colon cancer for average-risk veterans in healthcare institutions.

Have we increased our efforts to identify strategies which encourage colorectal cancer screening in primary care patients? A review of research outputs over time

Globally, colorectal cancer (CRC) screening rates remain suboptimal. Primary care practitioners are supported by clinical practice guidelines which recommend they provide routine CRC screening advice. Published research can provide evidence to improve CRC screening in primary care, however this is dependent on the type and quality of evidence being produced. This review aimed to provide a snapshot of trends in the type and design quality of research reporting CRC screening among primary care patients across three time points: 1993-1995, 2003-2005 and 2013-2015. Four databases were searched using MeSH headings and keywords. Publications in peer-reviewed journals which reported primary data on CRC screening uptake among primary care patients were eligible for inclusion. Studies meeting eligibility criteria were coded as observational or intervention. Intervention studies were further coded to indicate whether or not they met Effective Practice and Organisation of Care (EPOC) study design criteria. A total of 102 publications were included. Of these, 65 reported intervention studies and 37 reported observational studies. The proportion of each study type did not change significantly over time. The majority of intervention studies met EPOC design criteria at each time point. The majority of research in this field has focused on testing strategies to increase CRC screening in primary care patients, as compared to research describing rates of CRC screening in this population. Further research is needed to determine which effective interventions are most likely to be adopted into primary care.

Insurance Coverage for CT Colonography Screening: Impact on Overall Colorectal Cancer Screening Rates

RSNA, 2017.

Testing the Effectiveness of a Primary Care Intervention to Improve Uptake of Colorectal Cancer Screening: A Randomized Controlled Trial Protocol

BACKGROUND

Screening for colorectal cancer (CRC) significantly reduces mortality associated with this disease. In Australia, the National Bowel Cancer Screening Program provides regular fecal occult blood tests (FOBT) for those aged 50 to 74 years, however, participation rates in the program have plateaued at 36%. Given low uptake in the National Bowel Cancer Screening Program, it is necessary to explore alternate methods to increase CRC screening rates. Primary care is a promising adjunct setting to test methods to increase CRC screening participation. Primary care guidelines support the recommendation and provision of CRC screening to primary care patients. Those in the National Bowel Cancer Screening Program target age range frequently present to their primary care provider.

OBJECTIVE

This study tests the effect that a multicomponent primary care-based intervention has on CRC screening uptake when compared to usual care.

METHODS

Primary care patients presenting for an appointment with their primary care provider complete a touchscreen survey to determine eligibility for the trial. Those aged 50 to 74 years, at average risk of CRC, with no history of CRC or inflammatory bowel disease, who have not had an FOBT in the past 2 years or a colonoscopy in the past 5 years are eligible to participate in the trial. Trial participants are randomized to the intervention or usual care group by day of attendance at the practice. The intervention consists of provision of an FOBT, printed information sheet, and primary care provider endorsement to complete the FOBT. The usual care group receives no additional care.

RESULTS

The primary outcome is completion of CRC screening 6 weeks after recruitment. The proportion of patients completing CRC screening will be compared between trial groups using a logistic regression model.

CONCLUSIONS

CRC screening rates in Australia are suboptimal and interventions to increase screening participation are urgently required. This protocol describes the process of implementing a multicomponent intervention designed to increase CRC screening uptake in a primary care setting.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12616001299493; https://anzctr.org.au/Trial/Registration/TrialReview.aspx?id=371136&isReview=true (Archived by WebCite at http://www.webcitation.org/6pL0VYIj6). Universal Trial Number U1111-1185-6120.

Influences and Practices in Colorectal Cancer Screening Among Health Care Providers Serving Northern Plains American Indians, 2011-2012

Introduction

The epidemiology of colorectal cancer, including incidence, mortality, age of onset, stage of diagnosis, and screening, varies regionally among American Indians. The objective of the Improving Northern Plains American Indian Colorectal Cancer Screening study was to improve understanding of colorectal cancer screening among health care providers serving Northern Plains American Indians.

Methods

Data were collected, in person, from a sample of 145 health care providers at 27 health clinics across the Northern Plains from May 2011 through September 2012. Participants completed a 32-question, self-administered assessment designed to assess provider practices, screening perceptions, and knowledge.

Results

The proportion of providers who ordered or performed at least 1 colorectal cancer screening test for an asymptomatic, average-risk patient in the previous month was 95.9% (139 of 145). Of these 139 providers, 97.1% ordered colonoscopies, 12.9% ordered flexible sigmoidoscopies, 73.4% ordered 3-card, guaiac-based, fecal occult blood tests, and 21.6% ordered fecal immunochemical tests. Nearly two-thirds (64.7%) reported performing in-office guaiac-based fecal occult blood tests using digital rectal examination specimens. Providers who reported receiving a formal update on colorectal cancer screening during the previous 24 months were more likely to screen using digital rectal exam specimens than providers who had received a formal update on colorectal cancer screening more than 24 months prior (73.9% vs 56.9%, respectively, χ² = 4.29, P = .04).

Conclusion

Despite recommendations cautioning against the use of digital rectal examination specimens for colorectal cancer screening, the practice is common among providers serving Northern Plains American Indian populations. Accurate up-to-date, ongoing education for patients, the community, and health care providers is needed.

Colorectal Cancer Screening in US Seniors Ages 76-84 Years

The US Preventive Services Task Force recommends patient-physician discussions about the appropriateness of colorectal cancer (CRC) screening among adults ages 76-84 years who have never been screened. In this study, we used data from the 2010 National Health Interview Survey to examine patterns of CRC screening and provider recommendation among seniors ages 76-84 years, and made some comparisons to younger adults. Nationally-representative samples of 1379 adults ages 76-84 years and 8797 adults ages 50-75 years responded to questions about CRC screening status, receipt of provider recommendation, and discussion of test options; 22.7% (95% CI 20.1-25.3) of seniors ages 76-84 had never been tested for CRC and therefore were not up-to-date with guidelines; 3.9% (95% CI 2.0-7.6) of these individuals reported a recent provider recommendation for screening. In multivariate analyses, the likelihood of never having been tested was significantly greater for seniors of other/multiple race or Hispanic ethnicity; with high school or less education; without private health insurance coverage; who had ≤ 1 doctor visit in the past year; without recent screening for breast, cervical, or prostate cancer; with no or unknown CRC family history; or with ≤ 1 chronic disease. Among the minority of respondents ages 50-75 and 76-84 reporting a provider recommendation, 73.2% indicated that the provider recommended particular tests, which was overwhelmingly colonoscopy (≥ 89 %). Nearly one-quarter of adults 76-84 have never been screened for CRC, and rates of provider recommendation in this group are very low. Greater attention to informed CRC screening discussions with screening-eligible seniors is needed.

Organizational Factors Affecting the Likelihood of Cancer Screening Among VA Patients

BACKGROUND

Preventive service delivery, including cancer screenings, continues to pose a challenge to quality improvement efforts. Although many studies have focused on person-level characteristics associated with screening, less is known about organizational influences on cancer screening.

OBJECTIVES

This study aims to understand the association between organizational factors and adherence to cancer screenings.

METHODS

This study employed a cross-sectional design using organizational-level, patient-level, and area-level data. Dependent variables included breast, cervical, and colorectal cancer screening. Organizational factors describing resource sufficiency were constructed using factor analyses from a survey of 250 Veterans Affairs primary care directors. We conducted random-effects logistic regression analyses, modeling cancer screening as a function of organizational factors, controlling for patient-level and area-level factors.

RESULTS

Overall, 87% of the patients received mammograms, 92% received cervical and 78% had colorectal screening. Quality improvement orientation increased the odds of cervical [odds ratio (OR): 1.27; 95% confidence interval (CI), 1.03-1.57] and colorectal cancer screening (OR: 1.10; 95% CI, 1.00-1.20). Authority in determining primary care components increased the odds of mammography screening (OR: 1.23; 95% CI, 1.03-1.51). Sufficiency in clinical staffing increased the odds of mammography and cervical cancer screenings. Several patient-level factors, serving as control variables, were associated with achievement of screenings.

CONCLUSIONS

Resource sufficiency led to increased odds of screening possibly because they promote excellence in patient care by conveying organizational goals and facilitate goal achievement with resources. Complementary to patient-level factors, our findings identified organizational processes associated with better performance, which offer concrete strategies in which facilities can evaluate their capabilities to implement best practices to foster and sustain a culture of quality care.

The Effectiveness of a Physician-Only and Physician-Patient Intervention on Colorectal Cancer Screening Discussions Between Providers and African American and Latino Patients

BACKGROUND

Physician recommendation of colorectal cancer (CRC) screening is a critical facilitator of screening completion. Providing patients a choice of screening options may increase CRC screening completion, particularly among racial and ethnic minorities.

OBJECTIVE

Our purpose was to assess the effectiveness of physician-only and physician-patient interventions on increasing rates of CRC screening discussions as compared to usual care.

DESIGN

This study was quasi-experimental. Clinics were allocated to intervention or usual care; patients in intervention clinics were randomized to receipt of patient intervention.

PARTICIPANTS

Patients aged 50 to 75 years, due for CRC screening, receiving care at either a federally qualified health care center or an academic health center participated in the study.

INTERVENTION

Intervention physicians received continuous quality improvement and communication skills training. Intervention patients watched an educational video immediately before their appointment.

MAIN MEASURES

Rates of patient-reported 1) CRC screening discussions, and 2) discussions of more than one screening test.

KEY RESULTS

The physician-patient intervention (n = 167) resulted in higher rates of CRC screening discussions compared to both physician-only intervention (n = 183; 61.1 % vs.50.3 %, p = 0.008) and usual care (n = 153; 61.1 % vs. 34.0 % p = 0.03). More discussions of specific CRC screening tests and discussions of more than one test occurred in the intervention arms than in usual care (44.6 % vs. 22.9 %,p = 0.03) and (5.1 % vs. 2.0 %, p = 0.036), respectively, but discussion of more than one test was uncommon. Across all arms, 143 patients (28.4 %) reported discussion of colonoscopy only; 21 (4.2 %) reported discussion of both colonoscopy and stool tests.

CONCLUSIONS

Compared to usual care and a physician-only intervention, a physician-patient intervention increased rates of CRC screening discussions, yet discussions overwhelmingly focused solely on colonoscopy. In underserved patient populations where access to colonoscopy may be limited, interventions encouraging discussions of both stool tests and colonoscopy may be needed.

Physician Non-adherence to Colonoscopy Interval Guidelines in the Veterans Affairs Healthcare System

BACKGROUND & AIMS

Colonoscopy can decrease colorectal cancer (CRC) mortality, although performing this procedure more frequently than recommended could increase costs and risks to patients. We aimed to determine rates and correlates of physician non-adherence to guidelines for repeat colonoscopy screening and polyp surveillance intervals.

METHODS

We performed a multi-center, retrospective, observational study using administrative claims, physician databases, and electronic medical records (EMR) from 1455 patients (50-64 y old) who underwent colonoscopy in the Veterans Affairs healthcare system in fiscal year 2008. Patients had no prior diagnosis of CRC or inflammatory bowel disease, and had not undergone colonoscopy examinations in the previous 10 years. We compared EMR-documented, endoscopist-recommended intervals for colonoscopies with intervals recommended by the 2008 Multi-Society Task Force guidelines.

RESULTS

The overall rate of non-adherence to guideline recommendations was 36% and ranged from 3% to 80% among facilities. Non-adherence was 28% for patients who underwent normal colonoscopies, but 45%-52% after colonoscopies that identified hyperplastic or adenomatous polyps. Most of all recommendations that were not followed recommended a shorter surveillance interval. In adjusted analyses, non-adherence was significantly higher for patients whose colonoscopies identified hyperplastic (odds ratio [OR] = 3.1; 95% CI, 1.7-5.5) or high-risk adenomatous polyps (OR = 3.0; 95% CI, 1.2-8.0), compared to patients with normal colonoscopy examinations, but not for patients with low-risk adenomatous polyps (OR = 1.8; 95% CI, 0.9-3.7). Nonadherence was also associated with bowel preparation quality, geographic region, Charlson comorbidity score, and colonoscopy indication.

CONCLUSIONS

In a managed care setting with salaried physicians, endoscopists recommend repeat colonoscopy sooner than guidelines for more than one third of patients. Factors associated with non-adherence to guideline recommendations were colonoscopy findings, quality of bowel preparation, and geographic region. Targeting endoscopist about non-adherence to colonoscopy guidelines could reduce overuse of colonoscopy and associated healthcare costs.

Genetic architecture of colorectal cancer

Colorectal cancer (CRC) is a complex disease that develops as a consequence of both genetic and environmental risk factors. A small proportion (3-5%) of cases arise from hereditary syndromes predisposing to early onset CRC as a result of mutations in over a dozen well defined genes. In contrast, CRC is predominantly a late onset 'sporadic' disease, developing in individuals with no obvious hereditary syndrome. In recent years, genome wide association studies have discovered that over 40 genetic regions are associated with weak effects on sporadic CRC, and it has been estimated that increasingly large genome wide scans will identify many additional novel genetic regions. Subsequent experimental validations have identified the causally related variant(s) in a limited number of these genetic regions. Further biological insight could be obtained through ethnically diverse study populations, larger genetic sequencing studies and development of higher throughput functional experiments. Along with inherited variation, integration of the tumour genome may shed light on the carcinogenic processes in CRC. In addition to summarising the genetic architecture of CRC, this review discusses genetic factors that modify environmental predictors of CRC, as well as examples of how genetic insight has improved clinical surveillance, prevention and treatment strategies. In summary, substantial progress has been made in uncovering the genetic architecture of CRC, and continued research efforts are expected to identify additional genetic risk factors that further our biological understanding of this disease. Subsequently these new insights will lead to improved treatment and prevention of colorectal cancer.

Colorectal cancer screening at community health centers: A survey of clinicians' attitudes, practices, and perceived barriers

Objective

Colorectal cancer (CRC) screening rates remain lower among some racial/ethnic groups and individuals with low income or educational attainment who are often cared for within community health centers (CHCs). We surveyed clinicians in a network of CHCs to understand their attitudes, practice patterns, and perceived barriers to CRC screening.

Methods

A clinician survey was conducted in 2013 within the Community Health Applied Research Network (CHARN).

Results

180 clinicians completed the survey (47.9% response rate). Participants had an average of 11.5 (SD: 9.8) years in practice, 62% were female, and 57% were physicians. The majority of respondents somewhat agreed (30.2%) or strongly agreed (57.5%) that colonoscopy was the best screening test. However, only 15.8% of respondents strongly agreed and 32.2% somewhat agreed that colonoscopy was readily available for their patients. Fecal immunochemical testing (FIT), a type of fecal occult blood test (FOBT), was viewed less favorably; 24.6% rated FIT as very effective.

Conclusions

Although there are no data showing that screening colonoscopy is superior to FIT, CHC clinicians believe colonoscopy is the best CRC screening test for their patients, despite the high prevalence of financial barriers to colonoscopy. These attitudes could be due to lack of knowledge about the evidence supporting long-term benefits of fecal occult blood testing (FOBT), lack of awareness about the improved test characteristics of FIT compared to older guaiac-based FOBT, or the absence of systems to ensure adherence to regular FOBT screening. Interventions to improve CRC screening at CHCs must address clinicians' negative attitudes towards FIT.

•

We surveyed primary care clinicians in a nationwide network of Community Health Centers.

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The vast majority believed that colonoscopy was the best screening test for colorectal cancer.

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However, less than half agreed that colonoscopy was readily available for their patients.

•

Fecal occult blood testing was viewed far less favorably than colonoscopy.

•

These attitudes and barriers must be overcome to improve screening and reduce disparities.

Examining Factors Influencing Colorectal Cancer Screening of Rural Nebraskans Using Data from Clinics Participating in an Accountable Care Organization: A Study Protocol

Background: Although mortality rates of colorectal cancer (CRC) can be significantly reduced through increased screening, rural communities are still experiencing lower rates of screening compared to urban counterparts. Understanding and eliminating barriers to cancer screening will decrease cancer burden and lead to substantial gains in quality and quantity of life for rural populations. However, existing studies have shown inconsistent findings and fail to address how contextual and provider-level factors impact CRC screening in addition to individual-level factors. 

Purpose: The purpose of the study is to examine multi-level factors related to CRC screening, and providers’ perception of barriers and facilitators of CRC screening in rural patients cared for by accountable care organization (ACO) clinics.

Methods/Design: This is a convergent mixed method design. For the quantitative component, multiple data sources, such as electronic health records (EHRs), Area Resource File (ARF), and provider survey data, will be used to examine patient-, provider-, clinic-, and county-level factors. About 21,729 rural patients aged between 50 and 75 years who visited the participating ACO clinics in the past 12 months are included in the quantitative analysis. The qualitative methods include semi-structured in-depth interviews with healthcare professionals in selected rural clinics. Both quantitative and qualitative data will be merged for result interpretation. Quantitative data identifies “what” factors influence CRC screening, while qualitative data explores “how” these factors interact with CRC screening. The study setting is 10 ACO clinics located in nine rural Nebraska counties.

Discussion: This will be the first study examining multi-level factors related to CRC screening in the new healthcare delivery system (i.e., ACO clinics) in rural communities. The study findings will enhance our understanding of how the ACO model, particularly in rural areas, interacts with provider- and patient-level factors influencing the CRC screening rate of rural patients.

Heterogeneous demographic and cultural profiles of Chinese American patients nonadherent to colorectal cancer screening: a latent class analysis

BACKGROUND

Colorectal cancer (CRC) is one of the leading causes of cancer death in Chinese Americans, but their CRC screening rates remain low.

OBJECTIVE

We examined subgroups of Chinese American patients nonadherent to CRC screening guidelines to better inform clinical practices to effectively promote screening.

METHODS

Using latent class analysis of data from 327 participants recruited from 18 primary care clinics, we classified nonadherent patients based on sociodemographics, screening barriers, and attitudinal and clinical factors for CRC screening.

RESULTS

The best-fitting latent class analysis model described 3 distinctive classes: Western healthcare class (36%), Eastern healthcare class (18%), and mixed healthcare class (46%). Western healthcare class patients were highly educated, with average US residency of 20 years, a high level of English proficiency, the least Eastern cultural views of care, and the greatest exposure to physician recommendations, but reported having no time for screenings. Eastern healthcare class patients were highly educated seniors and recent immigrants with the least CRC knowledge and the most Eastern cultural views. Mixed healthcare class patients had low level of education, resided in the United States for 20 years, and half had sought services of their physicians for at least 3 years, but their knowledge and cultural views were similar to those of Eastern healthcare class patients.

CONCLUSIONS

Nonadherent Chinese American patients are heterogeneous. It is essential to have future intervention programs tailored to address specific screening beliefs and barriers for subtypes of nonadherent patients.

IMPLICATIONS FOR PRACTICE

Training primary care physicians to recognize patients' different demographic characteristics and healthcare beliefs may facilitate physicians' communication with patients to overcome their barriers and improve screening behaviors.

Using segmented regression analysis of interrupted time series data to assess colonoscopy quality outcomes of a web-enhanced implementation toolkit to support evidence-based practices for bowel preparation: a study protocol

BACKGROUND

While there is convincing evidence on interventions to improve bowel preparation for patients, the evidence on how to implement these evidence-based practices (EBPs) in outpatient colonoscopy settings is less certain. The Strategies to Improve Colonoscopy (STIC) study compares the effect of two implementation strategies, physician education alone versus physician education plus an implementation toolkit for staff, on adoption of three EBPs (split-dosing of bowel preparation, low-literacy education, teach-back) to improve pre-procedure and intra-procedure quality measures. The implementation toolkit contains a staff education module, website containing tools to support staff in delivering EBPs, tailored patient education materials, and brief consultation with staff to determine how the EBPs can be integrated into the existing workflow. Given adaptations to the implementation plan and intentional flexibility in the delivery of the EBPs, we utilize a pragmatic study to balance external validity with demonstrating effectiveness of the implementation strategies.

METHODS/DESIGN

Participants will include all outpatient colonoscopy physicians, staff, and patients from a convenience sample of six endoscopy settings. Aim #1 will explore the relative effect of two strategies to implement patient-level EBPs on adoption and clinical quality outcomes. We will assess the change in level and trends of clinical quality outcomes (i.e., adequacy of bowel preparation, adenoma detection) using segmented regression analysis of interrupted time series data with two groups (intervention and delayed start). Aim #2 will examine the influence of organizational readiness to change on EBP implementation. We use a PRECIS diagram to reflect the extent to which each indicator of the study was pragmatic versus explanatory, revealing a largely pragmatic study.

DISCUSSION

Implementation challenges have already motivated several adaptations to the original plan, reflecting the nature of implementation in real-world healthcare settings. The pragmatic study responds to the evolving needs of its healthcare partners and allows for flexibility in intervention delivery, thereby informing clinical decision-making in real-world settings. The current study will provide information about what works (intervention effectiveness), for whom it works (influence of Medicaid versus other insurance), in which contexts it works (setting characteristics that influence implementation), and how it works best (comparison of implementation strategies).

Physician use of persuasion and colorectal cancer screening

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

Effect of patient navigation on colorectal cancer screening in a community-based randomized controlled trial of urban African American adults

PURPOSE

In recent years, colorectal cancer (CRC) screening rates have increased steadily in the USA, though racial and ethnic disparities persist. In a community-based randomized controlled trial, we investigated the effect of patient navigation on increasing CRC screening adherence among older African Americans.

METHODS

Participants in the Cancer Prevention and Treatment Demonstration were randomized to either the control group, receiving only printed educational materials (PEM), or the intervention arm where they were assigned a patient navigator in addition to PEM. Navigators assisted participants with identifying and overcoming screening barriers. Logistic regression analyses were used to assess the effect of patient navigation on CRC screening adherence. Up-to-date with screening was defined as self-reported receipt of colonoscopy/sigmoidoscopy in the previous 10 years or fecal occult blood testing (FOBT) in the year prior to the exit interview.

RESULTS

Compared with controls, the intervention group was more likely to report being up-to-date with CRC screening at the exit interview (OR 1.55, 95 % CI 1.07-2.23), after adjusting for select demographics. When examining the screening modalities separately, the patient navigator increased screening for colonoscopy/sigmoidoscopy (OR 1.53, 95 % CI 1.07-2.19), but not FOBT screening. Analyses of moderation revealed stronger effects of navigation among participants 65-69 years and those with an adequate health literacy level.

CONCLUSIONS

In a population of older African Americans adults, patient navigation was effective in increasing the likelihood of CRC screening. However, more intensive navigation may be necessary for adults over 70 years and individuals with low literacy levels.

Influence of provider discussion and specific recommendation on colorectal cancer screening uptake among U.S. adults

OBJECTIVES

It is unclear if provider recommendations regarding colorectal cancer (CRC) screening modalities affect patient compliance. We evaluated provider-patient communications about CRC screening with and without a specific screening modality recommendation on patient compliance with screening guidelines.

METHODS

We used the 2007 Health Information National Trends Survey (HINTS) and identified 4283 respondents who were at least 50 years of age and answered questions about their communication with their care providers and CRC screening uptake. We defined being compliant with CRC screening as the use of fecal occult blood testing (FOBT) within 1 year, sigmoidoscopy within 5 years, or colonoscopy within 10 years. We used survey weights in all analyses.

RESULTS

CRC screening discussions occurred with 3320 (76.2%) respondents. Approximately 95% of these discussions were with physicians. Overall, 2793 (62.6%) respondents were current with CRC screening regardless of the screening modality. Discussion about screening (odds ratio (OR)=8.83; 95% confidence interval (CI): 7.20-10.84) and providers making a specific recommendation about screening modality rather than leaving it to the patient to decide (OR=2.04; 95% CI: 1.54-2.68) were associated with patient compliance with CRC screening guidelines.

CONCLUSION

Compliance with CRC screening guidelines is improved when providers discuss options and make specific screening test recommendations.

Health and well-being among physicians

BACKGROUND AND AIM

Physicians' attitudes towards disease prevention are crucial. The purposes of this study are to examine the prevalence of cardiovascular risk factors and adherence to international preventive screening programmes by a group of physicians.

METHODS

Online and paper format questionnaires were completed by a sample of 650 physicians from November 2010 to March 2011. The collected data included the main components of screening programmes, which are recommended in international guidelines.

RESULTS

The data show that 30.5% of male physicians currently smoke, 19.4 % are obese, 15.2% have hypertension, 38% are physically inactive and 10.9% have diabetes. Nearly all (95%) of the female participants and most (83%) of the male participants older than 45 years had never had a colonoscopy. Of the male physicians older than 55 years, 36.4% had never had prostate-specific antigen testing, and only 10.9% had undergone a digital rectal examination. Among the female physicians, 27.4% were obese, and 42% had never had a mammogram.

CONCLUSION

The prevalence of behavioural risk factors for cardiovascular disease is high among physicians. A substantial percentage of the practising physicians did not adhere to the age-specified preventive screening measures recommended in international guidelines.

Comparative effectiveness of audit-feedback versus additional physician communication training to improve cancer screening for patients with limited health literacy

BACKGROUND

We designed a continuing medical education (CME) program to teach primary care physicians (PCP) how to engage in cancer risk communication and shared decision making with patients who have limited health literacy (HL).

OBJECTIVE

We evaluated whether training PCPs, in addition to audit-feedback, improves their communication behaviors and increases cancer screening among patients with limited HL to a greater extent than only providing clinical performance feedback.

DESIGN

Four-year cluster randomized controlled trial.

PARTICIPANTS

Eighteen PCPs and 168 patients with limited HL who were overdue for colorectal/breast/cervical cancer screening.

INTERVENTIONS

Communication intervention PCPs received skills training that included standardized patient (SP) feedback on counseling behaviors. All PCPs underwent chart audits of patients' screening status semiannually up to 24 months and received two annual performance feedback reports.

MAIN MEASURES

PCPs experienced three unannounced SP encounters during which SPs rated PCP communication behaviors. We examined between-group differences in changes in SP ratings and patient knowledge of cancer screening guidelines over 12 months; and changes in patient cancer screening rates over 24 months.

KEY RESULTS

There were no group differences in SP ratings of physician communication at baseline. At follow-up, communication intervention PCPs were rated higher in general communication about cancer risks and shared decision making related to colorectal cancer screening compared to PCPs who only received performance feedback. Screening rates increased among patients of PCPs in both groups; however, there were no between-group differences in screening rates except for mammography. The communication intervention did not improve patient cancer screening knowledge.

CONCLUSION

Compared to audit and feedback alone, including PCP communication training increases PCP patient-centered counseling behaviors, but not cancer screening among patients with limited HL. Larger studies must be conducted to determine whether lack of changes in cancer screening were due to clinic/patient sample size versus ineffectiveness of communication training to change outcomes.

The colorectal cancer screening process in community settings: a conceptual model for the population-based research optimizing screening through personalized regimens consortium

Reducing colorectal cancer mortality by promoting screening has been a national goal for two decades. The NCI's Population-Based Research Optimizing Screening through Personalized Regimens (PROSPR) consortium is the first federal initiative to foster coordinated, transdisciplinary research evaluating the entire cancer screening process in community settings. PROSPR is creating a central data repository to facilitate research evaluating the breast, cervical, and colorectal cancer screening process across different patient populations, provider types, and delivery systems. Data are being collected and organized at the multiple levels in which individuals are nested (e.g., healthcare systems, facilities, providers, and patients). Here, we describe a conceptual model of the colorectal cancer screening process guiding data collection and highlight critical research questions that will be addressed through pooled data. We also describe the three research centers focused on colorectal cancer screening with respect to study populations, practice settings, and screening policies. PROSPR comprehensively elucidates the complex screening process through observational study, and has potential to improve care delivery beyond the healthcare systems studied. Findings will inform intervention designs and policies to optimize colorectal cancer screening delivery and advance the Institute of Medicine's goals of effective, efficient, coordinated, timely, and safe health care with respect to evidence-based cancer screening.

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

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

Informed choice vs. no choice in colorectal cancer screening tests: a prospective cohort study in real-life screening practice

OBJECTIVES

The objective of this study was to compare the level of adherence to colorectal cancer (CRC) screening programs among screening participants offered vs. not offered informed choices on screening modality.

METHODS

We recruited 10,606 screening participants aged 50-70 years, including 6,397 subjects who were offered a choice of yearly fecal immunochemical test (FIT) for up to 3 years vs. one colonoscopy, and 4,209 subjects who were offered either FIT or colonoscopy without choice. They were prospectively followed up for 3 years. The proportion of screening participants who returned their specimens in all subsequent years (FIT group) and the attendance rate of scheduled endoscopy appointment (colonoscopy group) were compared between those with vs. without choice.

RESULTS

The adherence rate with FIT was 97.6%, 84.1%, and 72.6% in the first 3 years of follow-up, respectively, among those who were offered a choice. The adherence rate with FIT was 97.5%, 78.4%, and 62.8%, respectively, among those without choices. The proportion of subjects attending colonoscopy was 95.7% (choice offered) and 90.6% (no choice). From binary logistic regression analysis, participants who were offered informed choice were significantly more likely to adhere to the program when compared with those without test choices (odds ratio (OR)=2.54, 95% confidence interval (CI): 2.30-2.82, P<0.001). The respective adjusted OR for the FIT and colonoscopy groups was 1.60 (95% CI: 1.42-1.80, P<0.001) and 2.53 (95% CI: 1.94-3.31, P<0.001).

CONCLUSIONS

This study found that patients who were offered an informed choice for screening had higher adherence rates than patients who were not offered a choice in real-life practices, suggesting that providing screening test options for CRC screening is preferred.

A conceptual model of the multiple stages of communication necessary to support patient-centered care

Patient-centered care requires that both healthcare providers and patients have access to comparative effectiveness research (CER), which provides direct comparisons of the risks and benefits of available clinical options. However, insufficient attention has been paid to developing the comprehensive communication systems necessary to ensure that CER reaches patients and healthcare providers. In this review, we propose a model of the multiple stages of CER communication necessary for patient-centered care and review the existing research and gaps in knowledge relevant to each stage. These stages include: promotion of the underlying concepts and value of CER; translation of CER results; dissemination of CER results; and utilization of the results of CER in shared decision-making between patients and providers. A comprehensive approach to CER communication is necessary to ensure that the growing interest in and availability of CER is able to support a more patient-centered model of healthcare.

Challenges in meeting Healthy People 2020 objectives for cancer-related preventive services, National Health Interview Survey, 2008 and 2010

INTRODUCTION

Healthy People (HP) is the US program that formulates and tracks national health objectives for the nation. The National Health Interview Survey (NHIS) is a designated data source for setting and evaluating several HP targets in cancer. We used data from the 2008 and 2010 NHIS to provide a benchmark for national performance toward meeting HP 2020 cancer-related objectives.

METHODS

HP 2020 cancer screening, provider counseling, and health care access objectives were selected. For each objective, NHIS measures for the overall population and several sociodemographic subgroups were calculated; the findings were compared with established HP 2020 targets.

RESULTS

From 2008 to 2010, rates of breast and cervical cancer screening declined slightly while colorectal cancer screening rates increased by 7 percentage points. Rates of cancer screening and provider counseling were below HP targets. Meeting HP targets seems less likely for subgroups characterized by low income, no health insurance, or no usual source of care. Meeting HP targets for access to health services will require an increase of 18 percentage points in the proportion of persons under age 65 with health insurance coverage and an increase of 10 percentage points in the proportion aged 18 to 64 with a usual source of care.

CONCLUSION

Whether HP objectives for cancer screening and health care access are met may depend on implementation of health care reform measures that improve access to and coordination of care. Better integration of clinical health care and community-based efforts for delivering high-quality screening and treatment services and elimination of health disparities are also needed.

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

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

Barriers to colorectal cancer screening among women in rural central Pennsylvania: primary care physicians' perspective

INTRODUCTION

Colorectal cancer (CRC) is the third leading cause of death among women in the USA. Rural populations have lower rates of CRC screening than their urban counterparts, and rural women have lower screening rates compared with rural men. The purpose of this qualitative study was to identify (1) beliefs of primary care physicians (PCPs) about CRC screening in rural communities, (2) factors that may cause gender disparities in CRC screening in rural areas, and (3) solutions to overcome those barriers.

METHODS

Semi-structured interviews were conducted with 17 PCPs practicing in rural central Pennsylvania. PCPs were asked about their CRC screening practices for women, availability of CRC screening services, reminder systems for CRC screening, and barriers to screening specific to their rural communities and to gender. Thematic analysis was used to identify major themes.

RESULTS

All 17 PCPs endorsed the importance of CRC screening, but believed that there are barriers to CRC screening specific to women and to rural location. All PCPs identified colonoscopy as their screening method of choice, and generally reported that access to colonoscopy services in their rural areas was not a significant barrier. Barriers to CRC screening for women in rural communities were related to (1) PCPs' CRC screening practices, (2) gender-specific barriers to CRC screening, (3) patient-related barriers, (4) community-related barriers, and (5) physician practice-related barriers. Physicians overwhelmingly identified patient education as necessary for improving CRC screening in their rural communities, but believed that education would have to come from a source outside the rural primary care office due to lack of resources, personnel, and time.

CONCLUSION

Overall, the PCPs in this study were motivated to identify ways to improve their ability to engage more eligible patients in CRC screening. These findings suggest several interventions to potentially improve CRC screening for women in rural areas, including encouraging use of other effective CRC screening modalities (eg fecal occult blood testing) when colonoscopy is not possible, systems-based reminders that leverage electronic resources and are not visit-dependent, and public health education campaigns aimed specifically at women in rural communities.

The mediating role of health professionals' recommendation in the uptake of colorectal cancer testing among older Chinese adults

The purpose of this study is to examine the mediating effect of health professionals' recommendations on the relationship between the characteristics of older Chinese adults and the use of colorectal cancer testing. This was a cross-sectional population-based telephone survey. A total of 2004 Chinese adults aged 50 or above were recruited between 2 and 28 May 2007 to complete an anonymous telephone survey. The survey covered demographics, perceived health status and susceptibility to cancer, utilization of complementary medicine, family history of cancer, and cancer screening behaviour. The uptake of flexible sigmoidoscopy/colonoscopy was 12%, of which only 3.4% had been recommended by health professionals. The effects of gender, a history of serious disease, perceptions related to health status and visiting doctor regularly on the flexible sigmoidoscopy/colonoscopy uptake were mediated by a health professional's recommendation. A health professional's recommendation can be a catalyst for the decision of undergoing a colorectal cancer screening test in older adult people, in particular for those who are more health-conscious. As health professionals can play a crucial role in the development of successful population-based colorectal cancer screening program, efforts should be made to facilitate them in making recommendations for colorectal cancer screening to targeted high-risk group.

Risk assessment and clinical decision making for colorectal cancer screening

BACKGROUND

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

OBJECTIVE

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

DESIGN

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

PARTICIPANTS

PCPs at an urban, academic safety-net institution.

MAIN MEASURES

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

KEY RESULTS

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

CONCLUSIONS

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

Comparison of colorectal cancer screening in veterans based on the location of primary care clinic

OBJECTIVES

To compare colorectal cancer screening rates in veterans receiving primary care (PC) in Veterans Administration (VA) community-based outpatient clinics (CBOCs) and VA medical centers (VAMCs).

METHODS

The VA Outpatient Care Files were used to identify 2 837 770 patients ≥ 50 years with ≥ 2 PC visits in 2010. Veterans undergoing screening/surveillance colonoscopy, sigmoidoscopy, fecal-occult-blood testing (FOBT), and double-contrast barium enema (DCBE) were identified from ICD-9-CM/CPT codes. Patients were categorized as VAMC (n = 1 403 273; 49.5%) or CBOC (1 434 497; 50.5%) based on where majority of PC encounters occurred and as high risk (n = 284 090) or average risk (n = 2 553 680) based on colorectal cancer risk factors and validated ICD-9-CM-based algorithms.

RESULTS

CBOC patients were older than VAMC (mean ages 69.3 vs 67.4 years; P < .001), more likely (P < .001) to be male (96.5% vs 95.1%), and white (67.8% vs 64.2%), but less likely to be high-risk (9.4% vs 10.5%; P < .001). Rates of colonoscopy, sigmoidoscopy, and DCBE were all lower in CBOC (P < .001). Among high-risk veterans, rates in CBOC and VAMC, respectively, were 27.4% versus 36.8% for colonoscopy, 1.3% versus 0.8% for sigmoidoscopy, and 0.8% versus 0.5% for DCBE. Among average-risk veterans, these rates were 1.3% versus 1.9%, 0.2% versus 0.1%, and 0.2% versus 0.1%, respectively. The differences remained after adjusting for age/comorbidity. The adjusted odds of colonoscopy for CBOC were 0.73 (95% confidence interval = 0.64-0.82) for average risk and 0.76 (95% confidence interval = 0.67-0.87) for high risk. In contrast, the use of FOBT was relatively similar in CBOCs and VAMCs among both high risk (11.1% vs 11.2%) and average risk (14.3% vs 14.1%). Screening rates were similar between those younger than 65 years and older than 65 years.

CONCLUSIONS

Veterans receiving PC in CBOCs are less likely to receive screening colonoscopy, sigmoidoscopy, and DCBE than VAMC according to VA records. The lower use in CBOC was not offset by higher use of FOBT, including the degree to which CBOC patients may be more reliant to use non-VA services. The clinical appropriateness of these differences merits further examination.

Cancer screening in the United States, 2013: a review of current American Cancer Society guidelines, current issues in cancer screening, and new guidance on cervical cancer screening and lung cancer screening

Each year the American Cancer Society (ACS) publishes a summary of its recommendations for early cancer detection, a report on data and trends in cancer screening rates, and select issues related to cancer screening. In this issue of the journal, current ACS cancer screening guidelines are summarized, as are updated guidelines on cervical cancer screening and lung cancer screening with low-dose helical computed tomography. The latest data on the use of cancer screening from the National Health Interview Survey also are described, as are several issues related to screening coverage under the Patient Protection and Affordable Care Act of 2010.

Communication about colorectal cancer screening in Britain: public preferences for an expert recommendation

BACKGROUND

Informed decision-making approaches to cancer screening emphasise the importance of decisions being determined by individuals' own values and preferences. However, advice from a trusted source may also contribute to autonomous decision-making. This study examined preferences regarding a recommendation from the NHS and information provision in the context of colorectal cancer (CRC) screening.

METHODS

In face-to-face interviews, a population-based sample of adults across Britain (n=1964; age 50-80 years) indicated their preference between: (1) a strong recommendation to participate in CRC screening, (2) a recommendation alongside advice to make an individual decision, and (3) no recommendation but advice to make an individual decision. Other measures included trust in the NHS and preferences for information on benefits and risks.

RESULTS

Most respondents (84%) preferred a recommendation (47% strong recommendation, 37% recommendation plus individual decision-making advice), but the majority also wanted full information on risks (77%) and benefits (78%). Men were more in favour of a recommendation than women (86% vs 81%). Trust in the NHS was high overall, but the minority who expressed low trust were less likely to want a recommendation.

CONCLUSION

Most British adults want full information on risks and benefits of screening but they also want a recommendation from an authoritative source. An 'expert' view may be an important part of autonomous health decision-making.

Breast and colorectal cancer screening: U.S. primary care physicians' reports of barriers

BACKGROUND

Primary care physicians (PCPs) play a key role in performing and referring patients for cancer screening. Understanding barriers to test use is critical to developing strategies that promote adherence to clinical guidelines, but current literature does not distinguish the extent to which barriers may be similar or unique across screening modalities.

PURPOSE

To describe PCPs' self-reported perceptions of barriers to screening for breast and colorectal cancer (CRC) and compare the top three barriers associated with these screening modalities.

METHODS

Cross-sectional data analyzed in 2011 from a nationally representative survey of 2478 PCPs in the U.S. in 2006-2007.

RESULTS

PCPs reported greater barriers for CRC screening than for mammography. Lack of patient follow-through to complete recommended screening and the inability to pay for tests were the main barriers perceived by PCPs for both types of screening. Another major barrier cited was that patients do not perceive CRC as a threat. This was a lesser concern for the well-diffused message about the need for mammography.

CONCLUSIONS

This is the first national study to provide a comparison of physician-perceived barriers to breast and CRC screening. Study results suggest that efforts to improve use of cancer screening, and CRC screening in particular, will require interventions at physician, practice, and health-system levels.

Sociodemographic differences in fears and mistrust contributing to unwillingness to participate in cancer screenings

Effective provider-patient relationships are vital for positive patient health outcomes. This analysis assessed sociodemographic differences in fears and mistrust related to the provider-patient relationship, which may contribute to unwillingness to participate in cancer screenings (CSs). The data are from a stratified, random-digit dial telephone questionnaire of non-institutionalized households in New York, Maryland, and Puerto Rico. Statistically significant results indicate that Hispanics, compared with Whites, were nearly two times more likely to report that fear of being a "guinea pig" and lacking trust in medical people would make them unwilling to participate in CSs. Additionally, those with less education were over two times more likely to indicate a fear of being embarrassed during the screening would make them unwilling to participate in CSs. These results highlight areas where health professionals can improve interactions with their patients and be attentive to their fears and/or mistrusts to promote CSs utilization.

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

BACKGROUND

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

OBJECTIVE

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

DESIGN

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

PARTICIPANTS

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

KEY RESULTS

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

CONCLUSIONS

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

Screening colonoscopy in the US: attitudes and practices of primary care physicians

BACKGROUND

Rising colorectal cancer (CRC) screening rates in the last decade are attributable almost entirely to increased colonoscopy use. Little is known about factors driving the increase, but primary care physicians (PCPs) play a central role in CRC screening delivery.

OBJECTIVE

Explore PCP attitudes toward screening colonoscopy and their associations with CRC screening practice patterns.

DESIGN

Cross-sectional analysis of data from a nationally representative survey conducted in 2006-2007.

PARTICIPANTS

1,266 family physicians, general practitioners, general internists, and obstetrician-gynecologists.

MAIN MEASURES

Physician-reported changes in the volume of screening tests ordered, performed or supervised in the past 3 years, attitudes toward colonoscopy, the influence of evidence and perceived norms on their recommendations, challenges to screening, and practice characteristics.

RESULTS

The cooperation rate (excludes physicians without valid contact information) was 75%; 28% reported their volume of FOBT ordering had increased substantially or somewhat, and the majority (53%) reported their sigmoidoscopy volume decreased either substantially or somewhat. A majority (73%) reported that colonoscopy volume increased somewhat or substantially. The majority (86%) strongly agreed that colonoscopy was the best of the available CRC screening tests; 69% thought it was readily available for their patients; 59% strongly or somewhat agreed that they might be sued if they did not offer colonoscopy to their patients. All three attitudes were significantly related to substantial increases in colonoscopy ordering.

CONCLUSIONS

PCPs report greatly increased colonoscopy recommendation relative to other screening tests, and highly favorable attitudes about colonoscopy. Greater emphasis is needed on informed decision-making with patients about preferences for test options.

Multilevel factors affecting quality: examples from the cancer care continuum

The complex environmental context must be considered as we move forward to improve cancer care and, ultimately, patient and population outcomes. The cancer care continuum represents several care types, each of which includes multiple technical and communication steps and interfaces among patients, providers, and organizations. We use two case scenarios to 1) illustrate the variability, diversity, and interaction of factors from multiple levels that affect care quality and 2) discuss research implications and provide hypothetical examples of multilevel interventions. Each scenario includes a targeted literature review to illustrate contextual influences upon care and sets the stage for theory-informed interventions. The screening case highlights access issues in older women, and the survivorship case illustrates the multiple transition challenges faced by patients, families, and organizations. Example interventions show the potential gains of implementing intervention strategies that work synergistically at multiple levels. While research examining multilevel intervention is a priority, it presents numerous study design, measurement, and analytic challenges.

Patient activation increases colorectal cancer screening rates: a randomized trial among low-income minority patients

BACKGROUND

Colorectal cancer (CRC) screening rates remain low among low-income and minority populations. The purpose of this study was to determine whether providing patients with screening information, activating them to ask for a screening test, and telephone barriers counseling improves CRC screening rates compared with providing screening information only.

METHODS

Patients were randomized to CRC screening information plus patient activation and barriers counseling (n = 138) or CRC screening information (n = 132). Barriers counseling was attempted among activated patients if screening was not completed after one month. CRC screening test completion was determined by medical record review at two months after the medical visit. Logistic regression was used to determine whether activated patients were more likely to complete CRC screening, after adjustment for confounding factors (e.g., demographic characteristics and CRC knowledge).

RESULTS

Patients were African American (72.2%), female (63.7%), had annual household incomes less than $20,000 (60.7%), no health insurance (57.0%), and limited health literacy skills (53.7%). In adjusted analyses, more patients randomized to the activation group completed a screening test (19.6% vs. 9.9%; OR = 2.35, 95% CI: 1.14-5.56; P = 0.020). In addition, more activated patients reported discussing screening with their provider (54.4% vs. 27.5%, OR = 3.29, 95% CI: 1.95-5.56; P < 0.001) and had more screening tests ordered (39.1% vs. 17.6%; OR = 3.40, 95% CI: 1.88-6.15; P < 0.001) compared with those in the control group.

CONCLUSION

Patient activation increased CRC screening rates among low-income minority patients.

IMPACT

Innovative strategies are still needed to increase CRC screening discussions, motivate providers to recommend screening to patients, as well as assist patients to complete ordered screening tests.

Patient and Provider Preferences for Colorectal Cancer Screening: How Does CT Colonography Compare to Other Modalities?

OBJECTIVES

Patient and provider preferences toward CT colonography (CTC) remain unclear. The primary goals of this study were 1) to investigate patient preferences for one of the currently recommended CRC screening modalities and 2) to evaluate provider preferences before and after review of updated guidelines.

METHODS

Cross-sectional survey of ambulatory-care patients and providers in the primary care setting. Providers were surveyed before and after reviewing the 2008 guidelines by the American Cancer Society, US Multisociety Task Force on Colorectal Cancer and the American College of Radiology.

RESULTS

Of 100 patients surveyed, 59% preferred colonoscopy, 17% fecal occult blood testing (FOBT), 14% stool DNA (sDNA) testing, and 10% CTC (P <0.001). The majority of those whose first choice was a stool-based test chose the alternate stool-based test as their second choice over CTC or colonoscopy (P<0.0001). Patients who preferred colonoscopy chose accuracy (76%) and frequency of testing (10%) as the most important test features, whereas patients who preferred a stool-based test chose discomfort (52%) and complications (23%). Of 170 providers surveyed, 96% chose colonoscopy, 2% FOBT, and 1% FOBT with flexible sigmoidoscopy (FS) (p < 0.0001). No providers chose CTC or sDNA as their preferred option before reviewing guidelines, and 89% kept their preference after review of guidelines. As a default option for patients who declined colonoscopy, 44% of providers chose FOBT, 12% FOBT+FS, 4% CTC, and 37% deferred to patient preference before review of guidelines. Of the 33% of providers who changed their preference after review of guidelines, 46% recommended CTC. Accuracy was the most influential reason for provider test choice.

CONCLUSIONS

Patients and providers prefer colonoscopy for CRC screening. Revised guidelines endorsing the use of CTC are unlikely to change provider preferences but may influence choice of default strategies for patients who decline colonoscopy.