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Effectiveness of a patient‐ and practice‐level colorectal cancer screening intervention in health plan members

: Evidence-based interventions have been found effective in increasing colorectal cancer (CRC) screening. Translating these successful interventions into real world settings, such as health plans, can be challenging. : CHOICE (Communicating Health Options through Information and Cancer Education) is a controlled trial to test the effectiveness of a patient- and practice-level intervention to increase use of recommended CRC screening tests. The patient-level intervention was a patient decision aid and stage-targeted brochures, mailed to eligible health plan members, to provide information about CRC, available screening tests, and how to obtain CRC screening at their physicians' practices. The practice-level intervention was academic detailing to prepare practices to facilitate CRC testing once the patient was activated by the decision aid. Surveys and claims data will be used to assess CRC screening test completion. : Thirty-two primary care practices in Florida and Georgia participated. The authors recruited 443 participating health plan members for the trial; 211 were patients in intervention practices, and 232 were in usual care practices. Study participants reflected an insured population; the majority were white and aged <60 years. The authors also mailed the intervention to 343 people from intervention practices who did not respond to the eligibility or baseline survey. Receipt of screening in that group will be compared with screening among 319 people from usual care practices who did not respond to these surveys using claims data. : The CHOICE study will demonstrate the effect of 2 combined evidence-based interventions on CRC screening test completion among health plan members. Cancer 2010. (c) 2010 American Cancer Society.

Factors Influencing Choices for Colorectal Cancer Screening Among Previously Unscreened African and Caucasian Americans: Findings from a Triangulation Mixed Methods Investigation

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

Increasing Patient/Physician Communications About Colorectal Cancer Screening in Rural Primary Care Practices

Rural populations as well as less educated people in the United States are less likely to receive colorectal cancer (CRC) screening than people living in urban areas and more educated people. We tested a computer tablet, Patient/Provider Communication Assistant (PPCA), which collected data, educated patients, and printed personalized notes to patients and providers encouraging conversation about CRC screening. Mixed model analyses using a prepost quasi-experimental design compared patient results during the comparison and intervention periods in 5 rural primary care practices on provider discussion about CRC screening, provider recommendation, and patient intention to be screened. Models including age, education, and literacy measures as covariates were examined. Providers talked with patients about CRC screening in general, and colonoscopy specifically more frequently after the PPCA than with the comparison group (P values = 0.04 and 0.01, respectively). Providers recommended CRC screening more often to patients in the intervention group than to the comparison group (P = 0.02). Patients planned to be screened, specifically with colonoscopy, more frequently after the intervention than in the comparison group (P = 0.003). There were no interactions between group and any of the covariates. Ninety-five percent of the patients, regardless of age or education, found the PPCA easy to use. Results indicated increased provider discussion and recommendation, and patients' intentions to obtain CRC screening, and in particular colonoscopy, for patients exposed to the intervention, regardless of the patients' age or literacy levels. The PPCA is a promising intervention method that is acceptable to rural patients.

Predictors of colorectal cancer screening from patients enrolled in a managed care health plan

Despite the growing recognition of the importance of colorectal cancer (CRC) screening in reducing cancer mortality, national screening rates are low, indicating a critical need to understand the barriers and remedies for underutilization of CRC screening tests. Using results from independent cross-sectional telephone surveys with patients aged>or=50 years performed before (2000; n=498) and after (2003; n=482) a quality improvement intervention for CRC screening within a large managed care health plan, the trends and predictors of CRC screening with fecal occult blood test (FOBT) and/or endoscopy (flexible sigmoidoscopy/colonoscopy) were examined from a patient perspective. In 2000, patient reported screening rates within guidelines were 38% for any test, 23% for endoscopy, and 22% for FOBT. In 2003, screening rates increased to 50% for any test, 39% for endoscopy, and 24% for FOBT. Having discussed CRC with a doctor significantly increased the odds of being screened (FOBT: odds ratio [OR], 2.09 [95% confidence interval (95% CI), 1.47-2.96]; endoscopy: OR, 2.33 [95% CI, 1.67-3.26]; and any test: OR, 2.86 [95% CI, 2.06-3.96]), and reporting barriers to CRC in general decreased the odds of being screened (FOBT: OR, 0.76 [95% CI, 0.60-0.95]; endoscopy: OR, 0.74 [95% CI, 0.60-0.92]; and any test: OR, 0.66 [95% CI, 0.54-0.80]). Although screening rates increased over the 3-year period, evidence was found of ongoing underutilization of CRC screening. The 2 strongest determinants of obtaining CRC screening were provider influence and patient barriers related to CRC screening in general, pointing to the need for multilevel interventions that target both the provider and patient.

Colorectal cancer screening among Latinos from U.S. cities along the Texas–Mexico border

Colorectal cancer (CRC) screening rates are comparatively low for U.S. Hispanics. To learn more about the factors influencing CRC screening among Hispanics living along the U.S.-Mexico border, 12 focus groups were conducted with Hispanic men and women aged 50 years and older in three Texas counties; Cameron County (Brownsville), Webb County (Laredo), and El Paso County, (El Paso). The focus group guide contained questions about health care behavior, knowledge about CRC, experiences with cancer, and factors that influence CRC screening. A total of 92 individuals participated with the majority aged 50-69 (75%). Twenty percent were born in the United States and 51% had lived in the United States for more than 20 years. Participants had low levels of education, income, and insurance coverage. The analysis revealed several overarching and contextual themes relating to knowledge, attitudes, beliefs, and emotions about cancer and CRC screening. A prevalent theme that emerged from all groups was frustration and a lack of confidence in the U.S. healthcare system. Few participants had been advised by their providers to obtain CRC screening. Lack of patient knowledge about colorectal cancer and screening appeared to be a critical factor influencing screening. Themes about death and pain due to cancer were prevalent as were cultural factors such as machismo and embarrassment. System level barriers such as cost, medical insurance and transportation also impacted screening. These findings suggest that strategies are needed to educate Hispanic residents of border communities about CRC and to motivate them to undergo CRC screening.

Barriers to Colorectal Cancer Screening Among Medicare Consumers

Few studies have examined lack of physician recommendation and other reasons for under-utilization of colorectal cancer (CRC) screening in the Medicare population. Data from a telephone survey conducted in 2001 in a random sample of Medicare consumers residing in North and South Carolina were used to examine barriers to CRC screening, focusing on consumers' reports of receiving a physician's recommendation to obtain CRC screening and reasons for not being screened. Analyses were restricted to respondents with no history of CRC (n = 1901). Descriptive statistics were used to characterize respondents' CRC screening status, receipt of a physician's recommendation for screening, and reasons for not being screened. Logistic regression modeling was used to examine factors associated with receiving a physician recommendation for fecal occult blood test, sigmoidoscopy, colonoscopy, any endoscopy, and any CRC test. Thirty-one percent of Medicare consumers had never been tested for CRC, and 18% had been tested but were not current with Medicare-covered intervals. Overall, 28% reported not receiving a physician recommendation for screening. Predictors of receiving a physician recommendation included sociodemographic (younger age, white race, more education), health status (increased CRC risk, comorbidity), and healthcare access (had a routine/preventive care visit in the past 12 months) factors. Lack of knowledge/awareness and the physician not ordering the test were commonly cited reasons for not having CRC tests. Colorectal cancer screening was under-utilized by Medicare consumers in two states, and lack of physician recommendation was an important contributing factor. Providing a benefit under the Medicare program does not ensure its widespread use by consumers or their physicians.

Determinants of colorectal cancer screening behavior among Chinese Americans

Colorectal cancer (CRC) is the most commonly diagnosed cancer among Chinese Americans and is the third leading cause of cancer death in this population. The objectives of this study were to determine the rates of CRC screening (via fecal occult blood test (FOBT), flexible sigmoidoscopy (FSIG), and colonoscopy) among Chinese Americans and predictors of utilizing these screening procedures. Participants (N = 206) completed a self-administered questionnaire assessing cancer screening behaviors and beliefs about perceived risk of developing cancer and treatment efficacy. A series of logistic regressions indicated that physician recommendation to obtain CRC screening significantly predicted whether Chinese Americans undergo FOBT, FSIG, or colonoscopy screening (p < 0.001). Acculturation and perceived risk of developing CRC did not predict obtaining any of the screening procedures. FOBT was the most commonly reported screening method used by respondents (65%), followed by FSIG (54%) and colonoscopy (49%). These findings highlight the need to make physicians more aware of the impact their recommendations have in determining CRC screening behavior among Chinese Americans.

Barriers to Colorectal Cancer Screening

Barriers to colorectal cancer (CRC) screening are not well understood. We sought to compare barriers to CRC screening reported by primary care physicians (PCPs) and by average-risk adults, and to examine characteristics of average-risk adults who identified lack of provider recommendation as a major barrier to CRC screening. This was a comparative study using data from the 1999-2000 Survey of Colorectal Cancer Screening Practices and the 2000 National Health Interview Survey (NHIS). We recruited nationally representative samples of PCPs (n= 1235) from the SCCSP and average-risk adults (n = 6497) from the NHIS. We measured barriers to CRC screening identified by PCPs and average-risk adults who were not current with screening. Both PCPs and average-risk adults identified lack of patient awareness and physician recommendation as key barriers to obtaining CRC screening. PCPs also frequently cited patient embarrassment/anxiety about testing and test cost/lack of insurance coverage, but few adults identified these as major barriers. Of adults not current with testing, those who had visited a doctor in the past year or had health insurance were more likely to report lack of physician recommendation as the main reason they were not up-to-date compared with their counterparts with no doctor visit or health insurance. Only 10% of adults not current with testing and who had a doctor visit in the past year reported receiving a screening recommendation. A need exists for continued efforts to educate the public about CRC and the important role of screening in preventing this disease. Practice-based strategies to systematically prompt health care providers to discuss CRC screening with eligible patients also are required.

Barriers to colorectal cancer screening: an educational diagnosis.

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