Delivery of cancer screening: how important is the preventive health examination?

Association of daily health behavior and activity of daily living in older adults in China

This study aims to describe the activity of daily living (ADL) situation and determine the relationship between health behavior and ADL among older adults in China. A cross-sectional, observational study was conducted in one urban community and one rural community in Chengdu (a city located in Southwest China), China, from October 2022 to March 2023. A total of 706 older adults were included in this study. The associations between health behaviour and ADL were assessed by logistic regression model. Of the 706 older adults, 169 (23.9%) were disabled in ADL. According to the logistic regression analysis, age (60-69 years old: OR = 0.015, 95% CI 0.007 to 0.035, P < 0.001; 70-79 years old: OR = 0.116, 95% CI 0.060 to 0.227, P < 0.001), resident(OR = 0.568, 95% CI 0.330 to 0.976, P = 0.041), chronic disease (0 type: OR = 0.023, 95% CI 0.001 to 0.379, P = 0.008; 1-4 types: OR = 0.357, 95% CI 0.219 to 0.582, P < 0.001), no exercise (OR = 4.562, 95% CI 2.263 to 8.026, P < 0.001), and physical examination (OR = 2.217, 95% CI 1.294 to 3.496, P = 0.003) were significantly associated with ADL among older adults in Southwest China. This study showed that older adults had a higher ADL disability ratio. Age, resident, chronic disease, exercise and physical examination were associated with ADL among older adults. The study indicates that medium/high exercise maybe a protective factor for older adults, and nursing staff can encourage older adults to exercise when carrying out primary prevention measures. The government and public health institutions should give special attention to older adults and help them to acquire the habit of having an annual physical examination.

Unmet Healthcare Needs among College Students during the COVID-19 Pandemic: Implications for System-Wide and Structural Changes for Service Delivery

Background: During the COVID-19 pandemic, college students faced health disparities in addition to a negative burden on academic performance; however, little is reported in the literature regarding healthcare utilization. Methods: A cross-sectional survey was conducted among consenting college student participants aged 18 or older from a Hispanic-serving institution. Descriptive and bivariate statistics were used to analyze demographic characteristics and the types of healthcare services needed by such characteristics. Logistic regression was used to adjust for noted sex differences in associations between reporting limited healthcare services and types of healthcare services. Results: The study population of 223 participants was mostly Hispanic/Latino (65%) and female (73%). Of the population, 11% reported they could not obtain needed healthcare services, with time being reported as the most common reason. Significant associations were found between seeking general healthcare services/routine screening, seeking mental health services, and seeking sexual health services with reporting limited healthcare services, with sex-adjusted odds ratios and 95% confidence intervals of 1.90 (95% CI: 1.08, 3.36), 3.21 (95% CI: 1.44, 4.15), and 2.58 (95% CI: 1.05, 6.35), respectively. Conclusions: Availability and inability to obtain health services may exacerbate college student health disparities. Targeted interventions are needed in the population to mitigate the potential burdens of unmet healthcare needs, particularly among minority college students.

The Impact of Health Delivery Integration on Cancer Outcomes

Although integrated health care has largely been associated with increases in prices and static or decreased quality across many disease states, it has shown some successes in improving cancer care. However, its impact is largely equivocal, making consensus statements difficult. Critically, integration does not necessarily translate to clinical coordination, which might be the true driver behind the success of integrated health care delivery. Moving forward, it is important to establish payment models that support clinical care coordination. Shifting from a fragmented health system to a coordinated one may improve evidence-based cancer care, outcomes, and value for patients.

Willingness to Receive Periodic Health Examination Based on the Health Belief Model Among the Elderly in Rural China: A Cross-Sectional Study

PURPOSE

This study aimed to explore factors affecting behavioral intention of receiving periodic health examinations (hereafter, BIE) among people aged 60 and over in rural China, namely, Shandong Province, using the extended health belief model (EHBM).

PATIENTS AND METHODS

Participants were selected using stratified multi-stage random sampling. Three cities were selected based on economic level. Subsequently, three counties and three villages were selected from each sample city and county. Finally, 30 respondents were selected from each sample village. Face-to-face surveys were conducted using a structured questionnaire between March and September 2017. Multiple linear regression was conducted to investigate the association between BIE and eight dimensions of EHBM: perceived susceptibility, perceived severity, perceived benefits, perceived barriers, perceived self-efficacy, cues to action, health knowledge, and social support.

RESULTS

Of the 509 rural respondents aged 60 years and older, the average score of behavioral intention was 4.43±0.80. Multivariate linear regression analysis demonstrated poor BIE among participants who were men, were current smoker, were current drinker, were aged 70 years or over, had lower social support, and perceived lower self-efficacy, less benefits, and more barriers. Among them, barriers were found to have the strongest association with BIE (B'=-0.556; p<0.001). Qualitative interviews revealed that reasons for not receiving periodic health examinations (PHE) included pain, cost, difficulty in finding a health care provider, time and scheduling, potential lack of trust in the physician, and value of the PHE.

CONCLUSION

This study highlighted the importance of psychological variables in the acceptance of PHE among the elderly in rural China and provided insights for further intervention designs targeting identified groups and performed by general practitioners. Addressing medical mistrust, strengthening, and enhancing one's social support network and health communication channels, such as bulletin boards, may serve to facilitate BIE.

Increasing Cancer Screening Rates in Primary Care

Screening for cancer has contributed to substantial reductions in death from several cancers and is one of the most cost-effective preventive interventions in all of health care. In the United States, primary care clinicians, their clinical teams, and the systems in which they work are primarily responsible for ensuring that screening occurs. In order to achieve the highest possible population-wide screening rates, primary care clinicians must embrace the responsibility to screen their entire enrolled patient population, institute several overarching general approaches to screening, and implement a combination of evidence-based interventions.

Cancer screening in the United States, 2019: A review of current American Cancer Society guidelines and current issues in cancer screening

Each year, the American Cancer Society publishes a summary of its guidelines for early cancer detection, data and trends in cancer screening rates, and select issues related to cancer screening. In this issue of the journal, the current American Cancer Society cancer screening guidelines are summarized, and the most current data from the National Health Interview Survey are provided on the utilization of cancer screening for men and women and on the adherence of men and women to multiple recommended screening tests.

The impact of travel time on colorectal cancer stage at diagnosis in a privately insured population

BACKGROUND

Rural residents are less likely to receive screening for colorectal cancer (CRC) than urban residents. However, the mechanisms underlying this disparity, especially among people aged 50-64 years old with private health insurance, are not well understood. We examined the impact of travel time on stage at CRC diagnosis.

METHODS

This retrospective cohort study used data from the Blue Cross and Blue Shield of Nebraska. Members of this private insurance company aged 50-64 years, diagnosed with CRC during the period 2012-2016, and continuously enrolled in the insurance plan for at least 6 months prior to CRC diagnosis, were selected for this study. Using Google Maps, we estimated patients' travel time from their home ZIP code to the ZIP code of their colonoscopy provider. Using logistic regression, we analyzed the association between stage at CRC diagnosis, travel time, use of preventive services (i.e., check-ups or counseling to prevent or detect illness at an early stage) and patient characteristics.

RESULTS

A total of 307 subjects met the inclusion criteria. People who had not used preventive services 6 months prior to CRC diagnosis had 2.80 (95% CI, 1.00-7.90) times the odds of metastatic CRC compared to those who had used these services. No statistically significant association was found between travel time and metastatic CRC diagnosis (P = 0.99; 95% CI, 0.98-1.01).

CONCLUSIONS

The fact that 13% of the study population presented with metastatic CRC suggests some noncompliance with preventive services such as screening guidelines. To increase screening uptake and reduce metastatic cases, employers should offer incentives for their employees to make use of preventive services such as CRC screening.

A blueprint for cancer screening and early detection: Advancing screening's contribution to cancer control

From the mid-20th century, accumulating evidence has supported the introduction of screening for cancers of the cervix, breast, colon and rectum, prostate (via shared decisions), and lung. The opportunity to detect and treat precursor lesions and invasive disease at a more favorable stage has contributed substantially to reduced incidence, morbidity, and mortality. However, as new discoveries portend advancements in technology and risk-based screening, we fail to fulfill the greatest potential of the existing technology, in terms of both full access among the target population and the delivery of state-of-the art care at each crucial step in the cascade of events that characterize successful cancer screening. There also is insufficient commitment to invest in the development of new technologies, incentivize the development of new ideas, and rapidly evaluate promising new technology. In this report, the authors summarize the status of cancer screening and propose a blueprint for the nation to further advance the contribution of screening to cancer control.

The prevalence change of hyperlipidemia and hyperglycemia and the effectiveness of yearly physical examinations: an eight-year study in Southwest China

Background

The aim of this study was to investigate the prevalence changes of hyperlipidemia and hyperglycemia from 2009 to 2016 and the effectiveness of yearly physical examinations to hyperlipidemia and hyperglycemia prevention in Chengdu.

Methods

A total of 794 residents (499 males) who have undergone annual health check-ups for 8 consecutive years (from 2009 to 2016) in Chengdu, a city in southwest China were selected as the follow-up group, 7226 residents in 2009 and 75,068 residents in 2016 who underwent health examinations in the same hospital were chosen to be the contemporary control group. The concentration of fasting serum triglyceride(TG), total cholesterol(TC), low density lipoprotein cholesterol(LDL-C), high density lipoprotein cholesterol (HDL-C) and glucose were measured and compared among these groups.

Results

There was a clear rise in the prevalence of hypercholesterolemia and hyperglycemia from 2009 to 2016 (p < 0.05). The follow-up group didn’t show difference in levels of serum lipids and glucose compared with the general population after an 8-years’ consecutive physical examination (p > 0.05), the follow-up cohort in the 8th year exhibited significant increases in serum total cholesterol and glucose compared with the 1st year (p < 0.05).

Conclusion

The prevalence of hypercholesterolemia and hyperglycemia were increased significantly from 2009 to 2016. Annual physical examination didn’t show a positive effect in the prevention of hypercholesterolemia and hyperglycemia. Health education should be improved to ensure the fulfillment of the preventive objective of yearly physical examination.

Influencing Cancer Screening Participation Rates-Providing a Combined Cancer Screening Program (a 'One Stop' Shop) Could Be a Potential Answer

Introduction

Participation in established cancer screening programs remains variable. Therefore, a renewed focus on how to increase screening uptake, including addressing structural barriers such as time, travel, and cost is needed. One approach could be the provision of combined cancer screening, where multiple screening tests are provided at the same time and location (essentially a ‘One Stop’ screening shop). This cohort study explored both cancer screening behavior and the acceptability of a combined screening approach.

Methods

Participants of the North Western Adelaide Health Study (NWAHS), South Australia were invited to participate in a questionnaire about cancer screening behaviors and the acceptability of a proposed ‘One Stop’ cancer screening shop. Data were collected from 10th August 2015 to 18th January 2016, weighted for selection probability, age, and sex and analyzed using descriptive and multivariable logistic regression analysis.

Results

1,562 people, 52% female (mean age 54.1 years ± 15.2) participated. Reported screening participation was low, the highest being for Pap Smear (34.4%). Common reasons for screening participation were preventing sickness (56.1%, CI 53.2–59.0%), maintaining health (51%, CI 48–53.9%), and free program provision (30.9%, CI 28.2–33.6%). Females were less likely to state that screening is not beneficial [OR 0.37 (CI 0.21–0.66), p < 0.001] and to cite sickness prevention [OR 2.10 (CI 1.46–3.00), p < 0.001] and free program [OR 1.75 (CI 1.22–2.51), p < 0.003] as reasons for screening participation. Of those who did not participate, 34.6% (CI 30.3–39.1%) stated that there was nothing that discouraged them from participation, with 55- to 64-year olds [OR 0.24 (CI 0.07–0.74), p < 0.04] being less likely to cite this reason. 21% (CI 17.2–24.8%) thought they did not need screening, while a smaller proportion stated not having time (6.9%, CI 4.9–9.7%) and the costs associated with screening (5.2%, CI 3.5–7.7%). The majority of participants (85.3%, CI 81.9–88.2%) supported multiple screening being offered at the same time and location.

Conclusion

Identified screening behaviors in this study are similar to those reported in the literature. The high support for the concept of combined cancer screening demonstrates that this type of approach is acceptable to potential end users and warrants further investigation.

Using a public health station for screening of undiagnosed dysglycemia and hypertension

AIM

Dysglycemia, diabetes and abnormal blood pressure screening can be conducted by trained volunteers and may identify unknown cases. The aim of the study was to examine the feasibility and effectiveness of operating a screening station in pubic setting supervised by diabetes unit.

METHODS

A cross-sectional analysis of a program offering free screening services to non-hospitalized subjects. From 1.1.2011 through 31.12.2013 trained volunteers measured height, weight, blood glucose and blood pressure at the main entrance of the hospital. Subjects were asked whether they had diabetes or hypertension. Dysglycemia was defined as blood glucose 141-199mg/dL and probable newly-identified diabetes as ≥200mg/dL.

RESULTS

13,112 adults underwent screening. Among the screened individuals (age 55.3±14.9 years) 2215 (16.9%) reported diabetes and 3037 (23.2%) hypertension. Among subjects without known hypertension, 9.6% had blood pressure ≥140/90. Among the subjects without known diabetes, 5012 (46%) had glucose ≤110mg/dL, 2873 (26.4%) ≥126mg/dL, 1553 (14.3%) >140mg/dL and 170 (1.6%) ≥200mg/dL. Compared to subjects with blood glucose ≤140mg/dL, those with dysglycemia or diabetes were older (58.9±13.4 vs. 52.7±15.2 years, P<0.001), had elevated BMI (27.5±4.6kg/m(2) vs. 26.6±4.6kg/m(2), P<0.001), higher systolic (137.5±22.2mmHg vs. 132.2±21.3mmHg, P<0.001) and diastolic blood pressure (80.3±15.6mmHg vs. 78.6±13.7mmHg, P<0.001). Compared to subjects with blood glucose<200mg/dL, those with probable newly-identified diabetes were older (58.6±10.9 vs. 53.5±15.2, P<0.001), had elevated BMI (28.4±4.8kg/m(2) vs. 26.7±4.6kg/m(2), P<0.001), higher systolic (139.4±24.0mmHg vs. 132.8±21.4mmHg, P<0.001) and diastolic blood pressure (85.4±20.7mmHg vs. 78.8±13.9mmHg, P<0.001).

CONCLUSIONS

Screening supervised by healthcare center can identify individuals at high-risk for dysglycemia and abnormal blood pressure, who are referred for further diagnosis and treatment and may serve as a complementary step in primary health care setting.

Breast cancer screening initiation after turning 40 years of age within the PROSPR consortium

PURPOSE

Although United States clinical guidelines differ, the earliest recommended age for average risk breast cancer screening is 40 years. Little is known about factors influencing screening initiation.

METHODS

We conducted a cohort study within the National Cancer Institute-funded Population-based Research Optimizing Screening through Personalized Regimens (PROSPR) consortium. We identified 3413 women on their 40th birthday in primary care networks at Geisel School of Medicine at Dartmouth (DH) and Brigham and Women's Hospital (BWH) during 2011-2013 with no prior breast imaging or breast cancer. Cumulative incidence curves and Cox modeling were used to determine time from the 40th birthday to first breast cancer screening, cohort exit, or 42nd birthday. We calculated hazards ratios and 95 % confidence intervals from multivariable Cox proportional hazards models.

RESULTS

Breast cancer screening cumulative incidence by the 42nd birthday was 62.9 % (BWH) and 39.8 % (DH). Factors associated with screening initiation were: a primary care visit within a year (HR 4.99, 95 % CI 4.23-5.89), an increasing number of primary care visits within a year (p for trend <0.0001), ZIP code of residence annual median household income ≤$52,000 (HR 0.79, 95 % CI 0.68-0.92), and health insurance type (Medicaid HR 0.72, 95 % CI 0.58-0.88; Medicare HR 0.55, 95 % CI 0.39-0.77; uninsured HR 0.37, 95 % CI 0.25-0.57).

CONCLUSIONS

Breast cancer screening uptake after the 40th birthday varies by health system, primary care visits, median household income, and health insurance type, suggesting the need for further exploration. Future research should evaluate screening performance metrics after initiation and consider cumulative benefits and risks associated with breast cancer screening over time.

Health, healthy lifestyles and health examinations among the older people in Taiwan

AIM

This aim of this study was to examine the relationship between the utilisation of general health examinations and health and a healthy lifestyle.

METHODS

The data were from a 5-wave panel of older Taiwanese people. Health was defined as the absence of chronic diseases and physical function difficulties. A healthy lifestyle included no smoking, no alcohol consumption and engaging in regular exercise. Generalised linear modelling was applied.

RESULTS

The individuals with more chronic diseases were more likely to undergo health examinations, but the rate of change declined over time. Having more physical function disabilities may reduce the likelihood of undergoing health examinations. Individuals who engaged in regular exercise were more likely to undergo health examinations.

CONCLUSION

Health examination utilisation is related to health and healthy lifestyle among older people.

Cancer screening in the United States, 2015: a review of current American cancer society guidelines and current issues in cancer screening

Each year, the American Cancer Society (ACS) publishes a summary of its guidelines for early cancer detection along with a report on data and trends in cancer screening rates and select issues related to cancer screening. In this issue of the journal, we summarize current ACS cancer screening guidelines. The latest data on utilization of cancer screening from the National Health Interview Survey (NHIS) also is described, as are several issues related to screening coverage under the Affordable Care Act, including the expansion of the Medicaid program.

Low rate of non-attenders to primary care providers in Israel - a retrospective longitudinal study

Background

A model that combines reactive and anticipatory care within routine consultations has become recognized as a cost-effective means of providing preventive health care, challenging the need of the periodic health examination. As such, opportunistic screening may be preferable to organized screening. Provision of comprehensive preventive healthcare within the primary care system depends on regular attendance of the general population to primary care physicians (PCPs). Objectives: To assess the proportion of patients who do not visit a PCP even once during a four-year period, and to describe the characteristics of this population.

Methods

An observational study, based on electronic medical records of 421,012 individuals who were members of one district of Clalit Health Services, the largest health maintenance organization in Israel.

Results

The average annual number of visits to PCPs was 7.6 ± 8.7 to 8.3 ± 9.0 (median 5, 25%-75% interval 1–11) and 9.5 ± 10.0 to10.2 ± 10.4 (median 6, 25%-75% interval 1–14) including visits to direct access consultants) in the four years of the study. During the first year of the study 87.2% of the population visited a PCP. During the four year study period, only 1.5% did not visit a PCP even once.

In a multivariate analysis having fewer chronic diseases (for each additional chronic disease the OR, 95% CI was 0.40 (0.38¬0.42)), being a new immigrant (OR, 95% CI 2.46 (2.32¬2.62)), and being male (OR, 95% CI 1.66 (1.58¬1.75)) were the strongest predictors of being a non-attender to a PCP for four consecutive years.

Conclusions

The rate of nonattendance to PCPs in Israel is low. Other than new immigrant status, none of the characteristics identified for nonattendance suggest increased need for healthcare services.

U.S. Preventive Services Task Force recommendations and cancer screening among female Medicare beneficiaries

BACKGROUND

Medicare covers several cancer screening tests not currently recommended by the U.S. Preventive Services Task Force (Task Force). In September 2002, the Task Force relaxed the upper age limit of 70 years for breast cancer screening recommendations, and in March 2003 an upper age limit of 65 years was introduced for cervical cancer screening recommendations. We assessed whether mammogram and Pap test utilization among women with Medicare coverage is influenced by changes in the Task Force's recommendations for screening.

METHODS

We identified female Medicare beneficiaries aged 66-80 years and used bivariate probit regression to examine the receipt of breast (mammogram) and cervical (Pap test) cancer screening reflecting changes in the Task Force recommendations. We analyzed 9,760 Medicare Current Beneficiary Survey responses from 2001 to 2007.

RESULTS

More than two-thirds reported receiving a mammogram and more than one-third a Pap test in the previous 2 years. Lack of recommendation was given as a reason for not getting screened among the majority (51% for mammogram and 75% for Pap). After controlling for beneficiary-level socioeconomic characteristics and access to care factors, we did not observe a significant change in breast and cervical cancer screening patterns following the changes in Task Force recommendations.

CONCLUSIONS

Although there is evidence that many Medicare beneficiaries adhere to screening guidelines, some women may be receiving non-recommended screening services covered by Medicare.

The influence of deductible health plans on receipt of the human papillomavirus vaccine series

PURPOSE

To evaluate whether enrollment in deductible health plans (DHP) with higher patient cost-sharing requirements than traditional health maintenance organization plans (HMP) decreased initiation and completion of the human papillomavirus (HPV) vaccine series recommended for prevention of cervical cancer.

METHODS

This was a retrospective observational study of 9- to 26-year-old females at Kaiser Permanente Georgia and Kaiser Permanente Colorado who were HPV vaccine naive at time of enrollment in a self-pay DHP or HMP in 2007. Estimates of rates of initiation and completion of the HPV vaccine series from plan enrollment in 2007 through December 2009 were obtained using Cox proportional hazards regressions (accounting for censoring) on samples matched on the propensity to enroll in a DHP versus HMP.

RESULTS

Initiation of the HPV vaccine series was 22.2% and 24.4% in the DHP and HMP groups, respectively, at Kaiser Permanente Georgia; completion was 12.3% and 14.4% in the DHP and HMP groups, respectively. Human papillomavirus vaccine series initiation was higher at Kaiser Permanente Colorado, but completion was lower. In the Cox proportional hazards regressions, rates of initiation and completion of the HPV vaccine series did not differ significantly (p ≤ .05) by plan type (DHP vs. HMP) at both sites. The primary care visit rate included in these regressions had a significant, positive association with initiation and completion of the HPV vaccine series.

CONCLUSIONS

Enrollment in a DHP versus an HMP did not directly affect initiation or completion of the HPV vaccine series among age-eligible females. Independent of plan type, more frequent primary care visits increased initiation and completion rates.

The use of annual physical examinations among the elderly in rural China: a cross-sectional study

Background

Periodic physical examination is considered helpful in preventing illness and promoting health among the elderly. Limited information is available about the use of annual physical examinations among the elderly in rural areas, however. This research explores the distribution characteristics of annual physical examination use and its determinants among people aged 60 or over in rural China.

Methods

A cross-sectional study was undertaken to estimate distribution characteristics of annual physical examination use and to collect data of sociodemographic characteristics, health knowledge level, and health communication channels. Participants were 1128 people aged 60 or over, randomly selected from four different provinces in the East, Mid-East, Mid-West, and West China. Logistic regression determined the predictors of annual physical examination use.

Results

Participants were predominantly aged 60–79 (44.1%) and 70–79 (42.0%). A total of 716 (63.5%) participants underwent annual physical examinations. Those who reported acquiring health knowledge via bulletin boards and village doctors had a higher probability of using annual physical examinations (OR = 3.15 and 1.53). The probability for civil servants/retired having annual physical examinations was 2.16 times higher than for farmers. Those who had an average level of health knowledge had a higher probability of using annual physical examinations than those at the below-average level (odds ratio: 2.07).

Conclusion

The government and public health institutions should assist farmers to acquire the habit of having annual physical examinations. Traditional channels, such as bulletin boards, should be used to deliver health information. Village doctors should be supported in delivering health information to the elderly in rural areas.

Cancer screening in the United States, 2014: a review of current American Cancer Society guidelines and current issues in cancer screening

Answer questions and earn CME/CNE Each year the American Cancer Society publishes a summary of its guidelines 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, we summarize current American Cancer Society cancer screening guidelines. In addition, the latest data on the use of cancer screening from the National Health Interview Survey is described, as are several issues related to screening coverage under the Patient Protection and Affordable Care Act, including the expansion of the Medicaid program.

Determinants of adherence to screening by colonoscopy in individuals with a family history of colorectal cancer

OBJECTIVE

Although first-degree relatives (FDRs) of colorectal cancer (CRC) patients, as a high-risk population, have the most to gain from colonoscopy screening, their adherence is suboptimal. Thus, an assessment of the determinants of adherence to screening is of potential importance.

METHODS

A cross-sectional study was conducted among 318 FDRs of 164 CRC patients treated at Tel-Aviv Sourasky Medical Center. Interviews were conducted with a questionnaire using I-Change Model.

RESULTS

Adherence to interval colonoscopy was low with only 73 FDRs (23.0%). Greater adherence was associated with socio-demographic variables (older age, siblings, having spouse, higher level of education and income) and behavioral variables (healthier lifestyle, utilization of preventive health services). Family physicians and kin were identified as the most influential figures on uptake. Intention, affective barriers, positive attitudes, social support, cues to action, age, and health maintenance were the strongest determinants of participation in CRC screening.

CONCLUSION

Adherence to colonoscopy is determined by multiple variables. Medical staff can play a key role in increasing adherence to colonoscopy.

PRACTICE IMPLICATIONS

Future interventions should focus on fostering positive attitudes, overcoming barriers, enhancing social support and providing a medical recommendation. Special efforts should be invested in young FDRs, those of low socio-economic status and those who underutilize preventive medicine.

Factors associated with adherence to fecal occult blood testing for colorectal cancer screening among adults in the Republic of Korea

PURPOSE

Repeated participation in fecal occult blood testing (FOBT) is one of the major factors affecting the long-term success of population-based colorectal cancer screening programs. The aim of this study is to explore strong factors linked to repeated participation in FOBT in the prior decade (2002-2011) among adults using the Health Belief Model (HBM) after controlling for other covariates.

METHODS

Data were obtained from South Korean adults, aged 50 years and over, who visited a national health screening center within a magnet hospital (N = 237). A pilot test was conducted to investigate the internal consistency of the HBM instruments and the clarity of survey questions. Sample characteristics and rates of adherence to FOBT screening were examined using means and frequencies. Important factors associated with adherence to FOBT were examined using multivariate logistic regression analysis.

RESULTS

About 44% of the respondents were adherent to FOBT screening over the prior decade. Four out of the six HBM-driven factors (perceived susceptibility, severity, and barriers, and health motivation) were statistically significant. Those with greater levels of susceptibility and health motivation and lower levels of severity and barriers were more likely to adhere to FOBT.

CONCLUSIONS

Health professionals should focus more on the four modifiable HBM-related factors to encourage adults to adhere to FOBT. Intervention programs, which lower perceived severity and barriers and increase susceptibility and health motivation, should be developed and implemented.

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.

Quality of care in systemic lupus erythematosus: application of quality measures to understand gaps in care

BACKGROUND

Systemic lupus erythematosus (SLE) affects 1 in 2500 Americans and is associated with significant morbidity and mortality. The recent development of SLE quality measures provides an opportunity to understand gaps in clinical care and to identify modifiable factors associated with variations in quality.

OBJECTIVE

To evaluate performance on SLE quality measures as well as differences in quality of care by demographic, socioeconomic, disease, and health system characteristics.

DESIGN AND PATIENTS

Cross-sectional analysis of data derived from the Lupus Outcomes Study, a prospective, longitudinal study of 814 individuals. Principal data collection was through annual structured telephone surveys between 2009-2010. Data on 13 SLE quality measures was collected. We used regression models to estimate demographic, socioeconomic, disease, and health system characteristics associated with performance on individual and overall quality measures.

OUTCOME MEASURES

Performance on each quality measure and overall performance on all measures for which participants were eligible (pass rate).

RESULTS

Participants were eligible for a mean of five measures (range 2-12). Performance varied from 29 % (assessment of cardiovascular risk factors) to 90 % (sun avoidance counseling). The overall pass rate was 65 % (95 % CI 64 %, 65 %). In unadjusted analyses, younger age, minority race/ethnicity, poverty, shorter disease duration, fewer physician visits, and lack of health insurance, were associated with lower pass rates. Receiving care in public sector managed care organizations was associated with higher pass rates. After adjustment, younger age, having fewer physician visits and lacking health insurance remained significantly associated with lower performance; receiving care in public sector managed care organizations remained associated with higher performance.

CONCLUSIONS

We identified a number of gaps in clinical care for SLE. Factors associated with the health care system, including presence and type of health insurance, were the primary determinants of performance on quality measures in SLE.

Health information technology: transforming chronic disease management and care transitions

Adoption of health information technology (HIT) is a key effort in improving care delivery, reducing costs of health care, and improving the quality of health care. Evidence from electronic health record (EHR) use suggests that HIT will play a significant role in transforming primary care practices and chronic disease management. This article shows that EHRs and HIT can be used effectively to manage chronic diseases, that HIT can facilitate communication and reduce efforts related to transitions in care, and that HIT can improve patient safety by increasing the information available to providers and patients, improving disease management and safety.

Cancer screening in the United States, 2012: A review of current American Cancer Society guidelines and current issues in 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 the latest data on the use of cancer screening from the National Health Interview Survey.

Prioritization of evidence-based preventive health services during periodic health examinations

BACKGROUND

Delivery of preventive services sometimes falls short of guideline recommendations.

PURPOSE

To evaluate the multilevel factors associated with evidence-based preventive service delivery during periodic health examinations (PHEs).

METHODS

Primary care physicians were recruited from an integrated delivery system in southeast Michigan. Audio recordings of PHE office visits conducted from 2007 to 2009 were used to ascertain physician recommendation for or delivery of 19 guideline-recommended preventive services. Alternating logistic regression was used to evaluate factors associated with service delivery. Data analyses were completed in 2011.

RESULTS

Among 484 PHE visits to 64 general internal medicine and family physicians by insured patients aged 50-80 years, there were 2662 services for which patients were due; 54% were recommended or delivered. Regression analyses indicated that the likelihood of service delivery decreased with patient age and with each concern the patient raised, and it increased with increasing BMI and with each additional minute after the scheduled appointment time the physician first presented. The likelihood was greater with patient-physician gender concordance and less if the physician used the electronic medical record in the exam room or had seen the patient in the past 12 months.

CONCLUSIONS

A combination of patient, patient-physician relationship, and visit contextual factors are associated with preventive service delivery. Additional studies are warranted to understand the complex interplay of factors that support and compromise preventive service delivery.

Promoting cancer screening within the patient centered medical home

While consensus has grown that primary care is the essential access point in a high-performing health care system, the current model of primary care underperforms in both chronic disease management and prevention. The Patient Centered Medical Home model (PCMH) is at the center of efforts to reinvent primary care practice, and is regarded as the most promising approach to addressing the burden of chronic disease, improving health outcomes, and reducing health spending. However, the potential for the medical home to improve the delivery of cancer screening (and preventive services in general) has received limited attention in both conceptualization and practice. Medical home demonstrations to date have included few evidence-based preventive services in their outcome measures, and few have evaluated the effect of different payment models. Decreasing use of hospitals and emergency rooms and an emphasis on improving chronic care represent improvements in effective delivery of healthcare, but leave opportunities for reducing the burden of cancer untouched. Data confirm that what does or does not happen in the primary care setting has a substantial impact on cancer outcomes. Insofar as cancer is the leading cause of death before age 80, the PCMH model must prioritize adherence to cancer screening according to recommended guidelines, and systems, financial incentives, and reimbursements must be aligned to achieve that goal. This article explores capacities that are needed in the medical home model to facilitate the integration of cancer screening and other preventive services. These capacities include improved patient access and communication, health risk assessments, periodic preventive health exams, use of registries that store cancer risk information and screening history, ability to track and follow up on tests and referrals, feedback on performance, and payment models that reward cancer screening.

Does pre-ordering tests enhance the value of the periodic examination? Study Design - Process implementation with retrospective chart review

Background

To evaluate the value of a pre-ordering process for the pro-active scheduling and completion of appropriate preventive and chronic disease monitoring tests prior to a periodic health examination (PHE).

Methods

A standardized template was developed and used by our nursing staff to identify and schedule appropriate tests prior to the patients PHE. Chart reviews were completed on all 602 PHE visits for a 3-month interval in a primary care setting. A patient satisfaction survey was administered to a convenience sample of the PHE patients.

Results

Of all the patients with tests pre-ordered, 87.8% completed the tests. All providers in the division used the process, but some evolved from one template to another over time. Most patients (61%) preferred to get their tests done prior to their PHE appointment. Many of our patients had abnormal test results. With this process, patients were able to benefit from face-to-face discussion of these results directly with their provider.

Conclusions

A pre-order process was successfully implemented to improve the value of the PHE visit in an internal medicine primary care practice using a standardized approach that allowed for provider autonomy. The process was accepted by patients and providers and resulted in improved office efficiency through reduced message handling. Completion of routine tests before the PHE office visit can help facilitate face-to-face discussions about abnormal results and subsequent management that otherwise may only occur by telephone.

Physician visits and colorectal cancer testing among Medicare enrollees in North Carolina and South Carolina, 2005

INTRODUCTION

Many Medicare enrollees do not receive colorectal cancer tests at recommended intervals despite having Medicare screening coverage. Little is known about the physician visits of Medicare enrollees who are untested. Our study objective was to evaluate physician visits of enrollees who lack appropriate testing to identify opportunities to increase colorectal cancer testing.

METHODS

We used North Carolina and South Carolina Medicare data to compare type and frequency of physician visits for Medicare enrollees with and without a colorectal cancer test in 2005. Type of physician visit was defined by the physician specialty as primary care, mixed specialty (more than 1 specialty, 1 of which was primary care), and nonprimary care. We used multivariate modeling to assess the influence of type and frequency of physician visits on colorectal cancer testing.

RESULTS

Approximately half (46.5%) of enrollees lacked appropriate colorectal cancer testing. Among the untested group, 19.8% had no physician visits in 2005. Enrollees with primary care visits were more likely to be tested than those without a primary care visit. Many enrollees who had primary care visits remained untested. Enrollees with visits to all physician types had a greater likelihood of having colorectal cancer testing.

CONCLUSION

We identified 3 categories of Medicare enrollees without appropriate colorectal cancer testing: those with no visits, those who see primary care physicians only, and those with multiple visits to physicians with primary and nonprimary care specialties. Different strategies are needed for each category to increase colorectal cancer testing in the Medicare population.

Should a colonoscopy be recommended for healthy individuals with increased carcinoembryonic antigen levels? A case-control study

BACKGROUND AND AIM

Despite the limitations of screening or early diagnosis of colorectal cancers (CRC), carcinoembryonic antigen (CEA) is frequently measured in practice and during health promotion programs. The aim of this study was to evaluate the role of colonoscopy in healthy individuals with elevated CEA levels.

METHODS

From January 2003 to November 2008, 117,731 healthy persons underwent an opportunistic screening program in two health promotion centers; 1,497 subjects (1.3%) showed an elevated CEA level (>5 ng/ml). Among them, 174 patients were recruited to undergo a colonoscopy to determine if colorectal malignancies were present. A total of 372 age- and sex-matched persons were selected as controls from among the healthy subjects who had a normal level of CEA and had received surveillance colonoscopy. The primary outcome was the incidences of CRC in elevated CEA and normal CEA groups. The secondary outcome was the predictive factors of CRC in the elevated CEA group.

RESULTS

The incidence of CRC was higher in the group with higher CEA-levels than in the group with normal CEA levels (4.6 vs. 1.3%; P=0.031). In the CEA-elevated group, patients with CRCs were diagnosed at more advanced stages than were those in the CEA-normal group. The incidence of colorectal polyps was not different between the two groups. In the CEA-elevated group, anemia was an independent predictive factor of CRCs by multivariate analysis (P=0.002).

CONCLUSION

Anemia itself is not a predictive factor of CRC in the entire population, but is an independent predictive factor of CRC in healthy individuals with an elevated level of CEA. Therefore, colonoscopy should be recommended for healthy subjects with an elevated level of CEA accompanied with anemia in the absence of other adenocarcinomas to evaluate the presence of colorectal malignancy.

Cancer screening in the United States, 2011: A review of current American Cancer Society guidelines and issues in 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. This article summarizes the current ACS guidelines, describes the anticipated impact of new health care reform legislation on cancer screening, and discusses recent public debates over the comparative effectiveness of different colorectal cancer screening tests. The latest data on the utilization of cancer screening from the National Health Interview Survey is described, as well as several recent reports on the role of health care professionals in adult utilization of cancer screening.

Impact of periodic health examination on surgical treatment for uterine fibroids in Beijing: a case-control study

Background

During the past 2 decades, there has been a rapid proliferation of "health examination center (HEC)" across China. The effects of their services on public's health have not been systemically investigated. This study aimed to assess the impact of periodic health examination (PHE) at HEC on surgical treatment for uterine fibroids in Beijing residents.

Methods

We identified 224 patients with a primary diagnosis of uterine fibroids who had surgical treatment at four Level-1 general hospitals in Beijing, from June 1, 2009 to October 20, 2009. Controls were women who did not have surgery for uterine fibroids, matched (1:1 ratio) for age (within 2 years). A standard questionnaire was used to inquire about whether participants had PHE at HEC during the previous 2 years.

Results

PHE at HEC within 2 years were associated with surgical treatment for uterine fibroids. Odds ratios was 4.05 (95% CI, 2.61-6.29 P < 0.001), after adjustment for marital status, whether have children, annual family income, health insurance, education level and self-rated uterine fibroids-related symptom severity.

Conclusions

Our study showed PHE currently provided at HEC in China were associated with significantly increased use of surgical treatment for uterine fibroids in women. Further studies are needed to assess the effects of PHE on clinical as well as on broad societal outcomes in Chinese in contemporary medical settings.

Longitudinal adherence with fecal occult blood test screening in community practice

PURPOSE

Although screening with fecal occult blood testing (FOBT) reduces colorectal cancer (CRC) mortality, its effectiveness may diminish if patients do not adhere with repeated screenings. Among patients who had previously engaged in FOBT screening, we assessed subsequent adherence with FOBT screening.

METHODS

We assessed longitudinal adherence with biennial FOBT screening (every other year) within a cohort of patients enrolled in an integrated Washington State health plan. Among 11,110 patients who participated in FOBT screening during a 2-year baseline period (2000-2001), we ascertained CRC screening use during a subsequent 2-year observation period (2002-2003). We used multinomial logistic regression to identify patient characteristics associated with higher incidence of repeat CRC screening (with or without FOBT) relative to patients who received no CRC screening.

RESULTS

Despite prior participation in FOBT screening, less than one-half of patients (44.4%; 95% CI, 42.9%-45.8%) completed FOBT screening during the 2-year observation period. Although 8.8% of patients (95% CI, 8.0%-9.7%) received other CRC tests without FOBT during the observation period, nearly one-half, 46.8% (95% CI, 45.3%-48.4%), received no CRC screening. After adjustment for other patient characteristics, receipt of a preventive health examination was strongly associated with FOBT adherence relative to no CRC screening (adjusted relative rate ratio = 11.16; 95% CI, 9.61-12.96).

CONCLUSIONS

Longitudinal adherence with FOBT screening was low in this insured population, potentially compromising its effectiveness in population CRC mortality reduction. Interventions to promote adherence may be necessary to achieve high effectiveness in population-based FOBT screening programs.

Intraclass correlation estimates for cancer screening outcomes: estimates and applications in the design of group-randomized cancer screening studies

BACKGROUND

Screening has become one of our best tools for early detection and prevention of cancer. The group-randomized trial is the most rigorous experimental design for evaluating multilevel interventions. However, identifying the proper sample size for a group-randomized trial requires reliable estimates of intraclass correlation (ICC) for screening outcomes, which are not available to researchers. We present crude and adjusted ICC estimates for cancer screening outcomes for various levels of aggregation (physician, clinic, and county) and provide an example of how these ICC estimates may be used in the design of a future trial.

METHODS

Investigators working in the area of cancer screening were contacted and asked to provide crude and adjusted ICC estimates using the analysis of variance method estimator.

RESULTS

Of the 29 investigators identified, estimates were obtained from 10 investigators who had relevant data. ICC estimates were calculated from 13 different studies, with more than half of the studies collecting information on colorectal screening. In the majority of cases, ICC estimates could be adjusted for age, education, and other demographic characteristics, leading to a reduction in the ICC. ICC estimates varied considerably by cancer site and level of aggregation of the groups.

CONCLUSIONS

Previously, only two articles had published ICCs for cancer screening outcomes. We have complied more than 130 crude and adjusted ICC estimates covering breast, cervical, colon, and prostate screening and have detailed them by level of aggregation, screening measure, and study characteristics. We have also demonstrated their use in planning a future trial and the need for the evaluation of the proposed interval estimator for binary outcomes under conditions typically seen in GRTs.

Primary care, economic barriers to health care, and use of colorectal cancer screening tests among Medicare enrollees over time

PURPOSE

Colorectal cancer (CRC) screening remains underutilized. The objective of this study was to examine the impact of primary care and economic barriers to health care on CRC testing relative to the 2001 Medicare expansion of screening coverage.

METHODS

Medicare Current Beneficiary Survey data were use to study community-dwelling enrollees aged 65 to 80 years, free of renal disease and CRC, and who participated in the survey in 2000 (n = 8,330), 2003 (n = 7,889), or 2005 (n = 7,614). Three outcomes were examined: colonoscopy/sigmoidoscopy within 5 years (recent endoscopy), endoscopy more than 5 years previously, and fecal occult blood test (FOBT) within 2 years.

RESULTS

Endoscopy use increased and FOBT use decreased during the 6-year period, with no significant independent differences between those receiving care from primary care physicians and those receiving care from other physicians. Beneficiaries without a usual place of health care were the least likely to undergo CRC testing, and that gap widened with time: adjusted odds ratio (AOR) = 0.27 (95% confidence interval [CI], 0.19-0.39) for FOBT, and AOR = 0.35 (95% CI, 0.27-0.46) for endoscopy in 2000 compared with AOR = 0.18 (95% CI, 0.11-0.30) for FOBT and AOR = 0.22 (95% CI, 0.17-0.30) for endoscopy in 2005. Disparities in use of recent endoscopy by type of health insurance coverage in both 2000 and 2005 were greater for enrollees with a high school education or higher than they were for less-educated enrollees. There were no statistically significant differences by delayed care due to cost after adjustment for health insurance.

CONCLUSION

Despite expanding coverage for screening, complex CRC screening disparities persisted based on differences in the usual place and cost of health care, type of health insurance coverage, and level of education.

The quality of preventive health care delivered to adults: results from a cross-sectional study in Southern Italy

BACKGROUND

It is assumed that providing clinical preventive services to patients can identify or detect early important causes of adult mortality. The aim of this study was to quantify access to preventive services in Southern Italy and to assess whether and how the provision of preventive care was influenced by any specific characteristics of patients.

METHODS

In a cross-sectional study adults aged 18 years and over attending primary care physician (PCP) offices located in Southern Italy were interviewed from June through December 2007. Quality indicators of preventive health care developed from RAND's Quality Assessment Tools and Behavioral Risk Factor Surveillance System (BRFSS) were used. Multivariate analysis was performed to identify and to assess the role of patients' characteristics on delivery of clinical preventive services.

RESULTS

A total of 1467 subjects participated in the study. Excepting blood pressure preventive check (delivered to 64.4% of eligible subjects) and influenza vaccination (recommended to 90.2% of elderly), the rates of delivery of clinical preventive services were low across all measures, particularly for screening and counseling on health habits. Rates for providing cancer screening tests at recommended times were 21.3% for colonoscopy, 51.5% for mammography and 52.4% for Pap smear. Statistical analysis showed clear disparities in the provision of clinical preventive services associated with age, gender, education level, perceived health status, current health conditions and primary care access measures.

CONCLUSIONS

There is overwhelming need to develop and implement effective interventions to improve delivery of routine clinical preventive services.

Psychosocial factors associated with routine health examination scheduling and receipt among African American men

INTRODUCTION

African American men often fail to obtain routine health examinations, which increases the probability of disease detection, yet little is known about psychosocial factors that motivate scheduling and receipt among this group.

METHODS

We used the Andersen model and theory of reasoned action as frameworks to evaluate the relative contribution of psychosocial factors to self-reported routine health examination scheduling and receipt in a cross-sectional sample of African American men (N = 386) recruited from barbershops (65.3%) and academic institutions/events (34.7%) in Michigan, Georgia, and North Carolina between 2003-2004 and 2007-2009. Participants completed measures assessing demographic factors, physical/mental health status, traditional male role norms, health-promoting male subjective norms, health value, and medical mistrust. Pearson's chi(2), analysis of variance, and multivariate logistic regression analyses were used to investigate associations between these study factors and routine health examination scheduling and receipt in the past year.

RESULTS

After final adjustment, the odds of scheduling a routine health examination were increased for men with a usual source of care (OR, 5.48; 95% CI, 3.06-9.78) and more health-promoting male subjective norms exposure (OR, 1.46; 95% CI, 1.02-2.04). Higher medical mistrust (OR, 0.26;; 95% CI, 0.09-0.76) and traditional male role norms (OR, 0.71; 95% CI, 0.52-0.98) reduced the odds of routine health examination receipt. The odds of routine health examination receipt were increased among men who were older (OR=1.05; 95% CI, 1.01-1.10), had a usual source of care (OR, 2.91; 95% CI, 1.54-5.51) and reported more male subjective norms exposure (OR, 1.51; 95% CI, 1.02-2.22).

CONCLUSIONS

Improving African American men's uptake of routine health examinations will require addressing medical mistrust, mitigating traditional masculine concerns about disclosing vulnerability, and leveraging male social networks.

Provision of preventive health care in systemic lupus erythematosus: data from a large observational cohort study

INTRODUCTION

Cancer and infections are leading causes of mortality in systemic lupus erythematosus (SLE) after diseases of the circulatory system, and therefore preventing these complications is important. In this study, we examined two categories of preventive services in SLE: cancer surveillance (cervical, breast, and colon) and immunizations (influenza and pneumococcal). We compared the receipt of these services in SLE to the general population, and identified subgroups of patients who were less likely to receive these services.

METHODS

We compared preventive services reported by insured women with SLE enrolled in the University of California, San Francisco Lupus Outcomes Study (n=685) to two representative samples derived from a statewide health interview survey, a general population sample (n=18,013) and a sample with non-rheumatic chronic conditions (n=4,515). In addition, using data from the cohort in both men and women (n=742), we applied multivariate regression analyses to determine whether characteristics of individuals (for example, sociodemographic and disease factors), health systems (for example, number of visits, involvement of generalists or rheumatologists in care, type of health insurance) or neighborhoods (neighborhood poverty) influenced the receipt of services.

RESULTS

The receipt of preventive care in SLE was similar to both comparison samples. For cancer surveillance, 70% of eligible respondents reported receipt of cervical cancer screening and mammography, and 62% reported colon cancer screening. For immunizations, 59% of eligible respondents reported influenza immunization, and 60% reported pneumococcal immunization. In multivariate regression analyses, several factors were associated with a lower likelihood of receiving preventive services, including younger age and lower educational attainment. We did not observe any effects by neighborhood poverty. A higher number of physician visits and involvement of generalist providers in care was associated with a higher likelihood of receiving most services.

CONCLUSIONS

Although receipt of cancer screening procedures and immunizations in our cohort was comparable to the general population, we observed significant variability by sociodemographic factors such as age and educational attainment. Further research is needed to identify the physician, patient or health system factors contributing to this observed variation in order to develop effective quality improvement interventions.

Comprehensive outpatient health assessment: a case-finding tool in 500 consecutive asymptomatic individuals

This study appraises the case-finding efficiency of a single-day outpatient program of a broad-based clinical evaluation and laboratory studies in asymptomatic adults. The same protocol, varied only according to age and sex, was used for 500 individuals encountered consecutively over 15 months, and an unanticipated new diagnosis or important clinical or laboratory finding was established for one-third of them. The diagnoses varied widely, consistent with the breadth of the observations, and most led to specific recommendations for care. These findings confirm the case-finding efficacy of comprehensive clinical assessments supported by basic laboratory studies and counter the notion that specific tests and/or portions of the review of systems and physical examination can be eliminated in establishing a reliable medical database for asymptomatic adults. In addition, such comprehensive data provide essential reference material for later comparisons.

Impact of age and comorbidity on colorectal cancer screening among older veterans

BACKGROUND

The Veterans Health Administration, the American Cancer Society, and the American Geriatrics Society recommend colorectal cancer screening for older adults unless they are unlikely to live 5 years or have significant comorbidity that would preclude treatment.

OBJECTIVE

To determine whether colorectal cancer screening is targeted to healthy older patients and is avoided in older patients with severe comorbidity who have life expectancies of 5 years or less.

DESIGN

Cohort study.

SETTING

Veterans Affairs (VA) medical centers in Minneapolis, Minnesota; Durham, North Carolina; Portland, Oregon; and West Los Angeles, California, with linked national VA and Medicare administrative claims.

PATIENTS

27 068 patients 70 years or older who had an outpatient visit at 1 of 4 VA medical centers in 2001 or 2002 and were due for screening.

MEASUREMENTS

The main outcome was receipt of fecal occult blood testing (FOBT), colonoscopy, sigmoidoscopy, or barium enema in 2001 or 2002, on the basis of national VA and Medicare claims. Charlson-Deyo comorbidity scores at the start of 2001 were used to stratify patients into 3 groups ranging from no comorbidity (score of 0) to severe comorbidity (score > or =4), and 5-year mortality was determined for each group.

RESULTS

46% of patients were screened from 2001 through 2002. Only 47% of patients with no comorbidity were screened despite having life expectancies greater than 5 years (5-year mortality, 19%). Although the incidence of screening decreased with age and worsening comorbidity, it was still 41% for patients with severe comorbidity who had life expectancies less than 5 years (5-year mortality, 55%). The number of VA outpatient visits predicted screening independent of comorbidity, such that patients with severe comorbidity and 4 or more visits had screening rates similar to or higher than those of healthier patients with fewer visits.

LIMITATIONS

Some tests may have been performed for nonscreening reasons. The generalizability of findings to persons who do not use the VA system is uncertain.

CONCLUSION

Advancing age was inversely associated with colorectal cancer screening, whereas comorbidity was a weaker predictor. More attention to comorbidity is needed to better target screening to older patients with substantial life expectancies and avoid screening older patients with limited life expectancies. primary funding source: VA Health Services Research and Development.

Influence of primary care use on population delivery of colorectal cancer screening

OBJECTIVE

Colorectal cancer (CRC) screening is commonly initiated during primary care visits. Thus, at the population level, limited primary care attendance may constitute a substantial barrier to CRC screening uptake. Within a defined population, we quantified the percent of CRC screening underuse that is potentially explained by low use of primary care visits.

METHODS

Among 48,712 adults ages 50 to 78 years eligible for CRC screening within a Washington state health plan, we estimated the degree to which a lack of CRC screening in 2002 to 2003 (fecal occult blood testing, sigmoidoscopy, or colonoscopy) was attributable to low primary care use, expressed as the population attributable risk percent (PAR%) associated with 0 to 3 primary care visits during the 2-year period.

RESULTS

In analyses adjusted for age, comorbidity, nonprimary care visit use, and prior preventive service use, low primary care use in 2002 to 2003 was strongly associated with a lack of CRC screening among both women and men. However, a majority of unscreened women and men had > or =4 primary care visits. Thus, whether low primary care use was defined as 0, 0 to 1, 0 to 2, or 0 to 3 primary care visits, the PAR% associated with low primary care use was large in neither women (range, 3.0-6.8%) nor men (range: 5.6-11.5%).

CONCLUSIONS

Health plan outreach efforts to encourage primary care attendance would be unlikely to substantially increase population uptake of CRC screening. In similar settings, resources might be more fruitfully devoted to the optimization of screening delivery during primary care visits that patients already attend.