Preferences for colorectal cancer screening tests and screening test use in a large multispecialty primary care practice

A Qualitative Study Exploring Barriers to Colorectal Cancer Screening Among Firefighters

OBJECTIVE

Firefighters are at increased risk of colorectal cancer (CRC), yet rates of CRC screening are low among this occupational group. This study examines perceived risks, barriers, and facilitators to CRC screening.

METHODS

Three semistructured focus group discussions were conducted by investigators in Tucson, AZ. Thematic analysis was used to identify patterns and themes in the data.

RESULTS

Three groups of firefighters (8 male (57%); 6 female (43%) mean age 50.4 ( SD = 12.2) years) voluntarily participated in the CRC discussions. Four major themes were examined: (1) perceptions of risk for CRC, (2) barriers to cancer screening, (3) facilitators to getting cancer screening, and (4) misinformation about CRC and screening.

CONCLUSIONS

Findings indicate unique perceptions, attitudes, and beliefs among firefighters. Results from this study will inform the adaptation of a tailored CRC screening intervention for firefighters.

Predictive factors based on the health belief model on cancer screening behaviour in first degree relatives of patients with Lynch syndrome-associated colorectal cancer

Objectives

This study aimed to investigate colorectal cancer-related knowledge, health beliefs, and screening behaviour in first-degree relatives (FDRs) of patients with Lynch syndrome-associated colorectal cancer (CRC) and explore the predictive factors of screening behaviour based on a health belief model.

Methods

This cross-sectional study was conducted in the colorectal department of a Class A tertiary hospital in Guangzhou from December 2017 to December 2019. A total of 265 FDRs of 96 patients with Lynch syndrome-related CRC were selected. The study was conducted in the colorectal department of a tertiary cancer centre in Guangzhou. The demographic questionnaire, the simplified CRC knowledge questionnaire, and the Champion's Health Belief Model Scale were used for evaluation. Data were analyzed using statistical description, between-group comparisons, and binary logistic regression.

Results

A total of 160 (60.4%), 61 (23.0%), and 44 (16.6%) of the participants had high, medium, and low levels of knowledge about CRC, respectively; the average overall score of health belief was 121.36 ± 13.02. Sixty-one participants (23.0%) underwent Lynch syndrome-associated cancer screening. The predictive factors of screening behaviour included sex (male), age (older), married status (married), multiple primary cancers of the index patients, and high levels of knowledge and health beliefs (P < 0.05).

Conclusions

The knowledge and health beliefs of cancer and cancer screening in FDRs of patients with Lynch syndrome-associated CRC should be improved. Both knowledge and beliefs are critical in promoting their cancer screening behaviour. Interventions should focus on health education and enhance health beliefs of the FDRs for better screening behaviour.

Results of an African American-targeted norm-based colorectal cancer screening intervention: a pilot study

Lower colorectal cancer screening rates among African Americans contribute to higher colorectal cancer incidence and mortality. We tested the effects of a racially-targeted messaging intervention that used favorable behavioral norm information to increase uptake of at-home Fecal Immunochemical Test (FIT) Kits. We expected stronger intervention effects among African Americans with stronger racial identity. Eligible African Americans were randomized to one of four intervention conditions: injunctive norm message, descriptive norm message, both messages, neither message. The norm-based messages were delivered via an animated video health message. Background variables, constructs defined by the theory of planned behavior, racial identity, screening modality preferences, and uptake and return of FIT Kits were assessed. Of 205 participants, 111(54%) requested FIT Kits. Contrary to hypotheses, multigroup path analyses indicated stronger effects of targeted messages among African Americans with weaker racial identity. Findings highlight the importance of within-race heterogeneity in the receptivity to racially-targeted health messages.

An Assessment of Physicians’ Recommendations for Colorectal Cancer Screening and International Guidelines Awareness and Adherence: Results From a Thai National Survey

Background

Colorectal cancer (CRC) screening uptake is generally low in the Asia Pacific and physicians’ recommendations affect the screening participation.

Objective

The study aimed to assess Thai physicians’ recommendations for CRC screening, and the awareness of and adherence to international guidelines.

Methods

A survey containing questions assessing physicians’ demographic data, screening recommendations, and awareness of the international CRC screening guidelines assessed by clinical vignettes. Independent predictors of physicians’ recommendations for CRC screening were determined by logistic regression analysis.

Results

Five hundred and eighty-sixth of 1,286 (46%) physicians completed the survey, and 58% of them offered CRC screening. The majority of colorectal surgeons (91%) and gastroenterologists (86%) endorsed screening, whereas 35% of primary care physicians recommended screening. The patient’s age was the only factor influencing the physician’s decision to offer CRC screening (OR, 2.75: 95% CI, 1.61–4.67). Colonoscopy was the most recommended modality among specialists, whereas 60% of primary care physicians offered fecal occult blood tests (FOBTs). The guidelines awareness was noted in 81% of participants, with the highest rates among gastroenterologists and colorectal surgeons. Gastroenterologists were more likely to adhere to the guidelines than surgeons, but both recommended shorter interval surveillance colonoscopy than guidelines recommendations in cases of small hyperplastic rectosigmoid polyps.

Conclusions

Recommendations for CRC screening and awareness of guidelines vary among different specialties. A low proportion of primary care physicians recommended screening and colorectal surgeons and gastroenterologists recommended shorter intervals for surveillance of small hyperplastic polyp than suggested by guidelines.

Colorectal cancer screening preferences among physicians and individuals at average risk: A discrete choice experiment

BACKGROUND

Guidelines include several options for average-risk colorectal cancer (CRC) screening that vary in aspects such as invasiveness, recommended frequency, and precision. Thus, patient and provider preferences can help identify an appropriate screening strategy. This study elicited CRC screening preferences of physicians and individuals at average risk for CRC (IAR).

METHODS

IAR aged 45-75 years and licensed physicians (primary care or gastroenterology) completed an online discrete choice experiment (DCE). Participants were recruited from representative access panels in the US. Within the DCE, participants traded off preferences between screening type, screening frequency, true-positive, true-negative, and adenoma true positive (physicians only). A mixed logit model was used to obtain predicted choice probabilities for colonoscopy, multi-target stool DNA (mt-sDNA), fecal immunochemical test (FIT), and methylated septin 9 (mSEPT9) blood test.

RESULTS

Preferences of IAR and physicians were affected by screening precision and screening type. IAR also valued more regular screening. Physicians preferred colonoscopy (96.8%) over mt-sDNA (2.8%; p < 0.001), FIT (0.3%; p < 0.001) and mSEPT9 blood test (0.1%; p < 0.01). IAR preferred mt-sDNA (38.8%) over colonoscopy (32.5%; p < 0.001), FIT (19.2%; p < 0.001), and mSEPT9 blood test (9.4%; p < 0.001). IAR naïve to screening preferred non-invasive screening (p < 0.001), while the opposite was found for those who previously underwent colonoscopy or sigmoidoscopy.

CONCLUSIONS

While physicians overwhelmingly preferred colonoscopy, preferences of IAR were heterogenous, with mt-sDNA being most frequently preferred on average. Offering choices in addition to colonoscopy could improve CRC screening uptake among IAR. This study used a discrete choice experiment in the US to elicit preferences of physicians and individuals at average risk for colorectal cancer screening modalities and their characteristics.

Health Care Provider Characteristics Associated With Colorectal Cancer Screening Preferences and Use

OBJECTIVE

To assess health care provider (HCP) preferences related to colorectal cancer (CRC) screening overall, and by HCP and patient characteristics.

PARTICIPANTS AND METHODS

We developed a survey based on the Theoretical Domains Framework to assess factors associated with CRC screening preferences in clinical practice. The survey was administered online November 6 through December 6, 2019, to a validated panel of HCPs drawn from US national databases and professional organizations. The final analysis sample included 779 primary care clinicians (PCCs) and 159 gastroenterologists (GIs).

RESULTS

HCPs chose colonoscopy as their preferred screening method for average-risk patients (96.9% (154/159) for GIs, 75.7% (590/779) for PCCs). Among PCCs, 12.2% (95/779) preferred multi-target stool DNA (mt-sDNA), followed by fecal immunochemical test (FIT), (7.3%; 57/779) and guaiac-based fecal occult blood test (gFOBT) (4.8%; 37/779). Preference among PCCs and GIs generally shifted toward noninvasive screening options for patients who were unable to undergo invasive procedures; concerned about taking time from work; unconvinced about need for screening; and refusing other screening recommendations. Among PCCs, preference for mt-sDNA over FIT and gFOBT was less frequent in larger compared with smaller clinical practices. Additionally, preference for mt-sDNA over FIT was more likely among PCCs with more years of clinical experience, higher patient volumes (> 25/day), and practice locations in suburban and rural settings (compared to urban).

CONCLUSION

Both PCCs and GIs preferred colonoscopy for CRC screening of average-risk patients, although PCCs did so less frequently and with approximately a quarter preferring stool-based tests (particularly mt-sDNA). PCCs' preference varied by provider and patient characteristics. Our findings underscore the importance of informed choice and shared decision-making about CRC screening options.

Colorectal Cancer Screening and Yield in a Mailed Outreach Program in a Safety-Net Healthcare System

BACKGROUND

Screening with fecal immunochemical testing (FIT) reduces colorectal cancer mortality; however, screening remains low in underserved populations. Mailed outreach, including an invitation letter, FIT, and test instructions, is an evidence-based strategy to improve screening.

AIMS

To examine screening completion and yield in a mailed outreach program in a safety-net healthcare system.

METHODS

We identified and mailed outreach invitations to patients due for screening in a large safety-net system between September 1, 2018, and August 31, 2019. We examined: (1) screening completion, the proportion of patients completing FIT or screening colonoscopy within 6 months of the mailed invitation; and (2) timely diagnostic colonoscopy, the proportion of patients completing colonoscopy within 6 months of positive FIT.

RESULTS

We mailed 14,879 invitations to 13,190 patients. Nearly half (n = 6098, 46.2%) of patients completed screening: 4,896 (80.3%) completed FIT through mailed outreach; 1,114 (18.3%) FIT through usual care; and 88 (1.4%) screening colonoscopy through usual care. Of patients with a positive FIT (n = 289), 50.5% completed diagnostic colonoscopy within 6 months, 10.7% within 6-12 months, and 4.8% after 12 months. A total of 8 cancers and 83 advanced adenomas were detected in the 191 patients completing diagnostic colonoscopy.

CONCLUSION

After implementing and scaling up mailed outreach in a safety-net system, about half of patients completed screening, and the majority did so through mailed outreach. However, many patients failed to complete diagnostic colonoscopy after positive FIT. Results highlight the importance of adapting mailed outreach programs to local contexts and constraints of healthcare systems, in order to support efforts to improve CRC screening in underserved populations.

Initial validation of a self-report questionnaire based on the Theoretical Domains Framework: determinants of clinician adoption of a novel colorectal cancer screening strategy

BACKGROUND

Colorectal cancer (CRC) screening for average risk adults age 45 and older continues to be underutilized in the USA. One factor consistently associated with CRC screening completion is clinician recommendation. Understanding the barriers and facilitators of clinical adoption of emerging CRC screening strategies is important in developing effective intervention strategies to improve CRC screening rates. We aimed to develop a questionnaire based on the Theoretical Domains Framework (TDF) to assess determinants of clinical adoption of novel CRC screening strategies, using the multi-target stool DNA test (mt-sDNA; Cologuard®) as an example, and test the psychometric properties of this questionnaire on a sample of US clinicians.

METHODS

A web survey was administered between November and December 2019 to a national panel of clinicians including primary care clinicians (PCCs) and gastroenterologists (GIs) to assess 10 TDF constructs with 55 items. Confirmatory factor analysis (CFA) was used to examine whether the a priori domain structure was supported by the data. Discriminant validity of domains was tested with Heterotrait-Monotrait ratio (HTMT). Internal consistency for each scale was assessed using Cronbach's alpha. Criterion validity was assessed with self-reported mt-sDNA use and mt-sDNA recommendation as the outcomes.

RESULTS

Complete surveys were received from 814 PCCs and 159 GIs (completion rate, 24.7% of 3299 PCCs and 29.6% of 538 GIs). Providers were excluded from analysis if they indicated not recommending CRC screening to average-risk patients (final N = 973). The final questionnaire consisted of 38 items covering 5 domains: (1) knowledge; (2) skills; (3) identity and social influence; (4) optimism, beliefs about consequences, and intentions; and (5) environmental context and resources. CFA results confirmed a reasonable fit (CFI = 0.948, SRMR = 0.057, RMSEA = 0.080). The domains showed sufficient discriminant validity (HTMT < 0.85), good internal consistency (McDonald's omega > 0.76), and successfully differentiated providers who reported they had ordered mt-sDNA from those who never ordered mt-sDNA and differentiated providers who reported routinely recommending mt-sDNA from those who reported not recommending mt-sDNA.

CONCLUSIONS

Findings provide initial evidence for the validity and internal consistency of this TDF-based questionnaire in measuring potential determinants of mt-sDNA adoption for average-risk CRC screening. Further investigation of validity and reliability is needed when adapting this questionnaire to other novel CRC screening strategy contexts.

Colorectal Cancer Screening: Have We Addressed Concerns and Needs of the Target Population?

Despite the recognized benefits of colorectal cancer (CRC) screening, uptake is still suboptimal in many countries. In addressing this issue, one important element that has not received sufficient attention is population preference. Our review provides a comprehensive summary of the up-to-date evidence relative to this topic. Four OVID databases were searched: Ovid MEDLINE® ALL, Biological Abstracts, CAB Abstracts, and Global Health. Among the 742 articles generated, 154 full texts were selected for a more thorough evaluation based on predefined inclusion criteria. Finally, 83 studies were included in our review. The general population preferred either colonoscopy as the most accurate test, or fecal occult blood test (FOBT) as the least invasive for CRC screening. The emerging blood test (SEPT9) and capsule colonoscopy (nanopill), with the potential to overcome the pitfalls of the available techniques, were also favored. Gender, age, race, screening experience, education and beliefs, the perceived risk of CRC, insurance, and health status influence one’s test preference. To improve uptake, CRC screening programs should consider offering test alternatives and tailoring the content and delivery of screening information to the public’s preferences. Other logistical measures in terms of the types of bowel preparation, gender of endoscopist, stool collection device, and reward for participants can also be useful.

National Survey of Patient Factors Associated with Colorectal Cancer Screening Preferences

Recommended colorectal cancer screening modalities vary with respect to safety, efficacy, and cost. Better understanding of the factors that influence patient preference is, therefore, critical for improving population adherence to colorectal cancer screening. To address this knowledge gap, we conducted a panel survey focused on three commonly utilized colorectal cancer screening options [fecal immunochemical test or guaiac-based fecal occult blood test (FIT/gFOBT), multi-target stool DNA (mt-sDNA) test, and colonoscopy] with a national sample of U.S. adults, ages 40-75 years and at average risk of colorectal cancer, in November 2019. Of 5,097 panelists invited to participate, 1,595 completed the survey (completion rate, 31.3%). Our results showed that when presented a choice between two colorectal cancer screening modalities, more respondents preferred mt-sDNA (65.4%) over colonoscopy, FIT/gFOBT (61%) over colonoscopy, and mt-sDNA (66.9%) over FIT/gFOBT. Certain demographic characteristics and awareness of and/or experience with various screening modalities influenced preferences. For example, uninsured people were more likely to prefer stool-based tests over colonoscopy [OR, 2.53; 95% confidence interval (CI), 1.22-5.65 and OR, 2.73; 95% CI, 1.13-7.47]. People who had heard of stool-based screening were more likely to prefer mt-sDNA over FIT/gFOBT (OR, 2.07; 95% CI, 1.26-3.40). People who previously had a stool-based test were more likely to prefer FIT/gFOBT over colonoscopy (OR, 2.75; 95% CI, 1.74-4.41), while people who previously had a colonoscopy were less likely to prefer mt-sDNA or FIT/gFOBT over colonoscopy (OR, 0.39; 95% CI, 0.24-0.63 and OR, 0.40; 95% CI, 0.26-0.62). Our survey demonstrated broad patient preference for stool-based tests over colonoscopy, contrasting the heavy reliance on colonoscopy for colorectal cancer screening in clinical practice and highlighting the importance of considering patient preference in colorectal cancer screening recommendations. PREVENTION RELEVANCE: Our national survey demonstrated broad patient preference for stool-based tests over colonoscopy, contrasting the heavy reliance on colonoscopy for colorectal cancer screening in clinical practice and highlighting the importance of considering patient preference in colorectal screening recommendations.

Patient Preferences in Surveillance: Findings From a Discrete Choice Experiment in the "My Follow-Up" Study

OBJECTIVES

Approximately 800 000 people die globally from colorectal cancer (CRC) every year. Prevention programs promote early detection, but for people with precancerous lesions, tailoring surveillance to include lifestyle-change programs could enhance prevention potential and improve outcomes.

METHODS

Those with intermediate or high-risk polyps removed during CRC screening colonoscopy within the Northern Ireland CRC Screening Programme were invited to complete 8 discrete choice questions about tailored surveillance, analyzed using random-parameters logit and a latent class modeling approach.

RESULTS

A total of 231 participants (77% male) self-reported comorbid hypertension (53%), high cholesterol (48%), and mean body mass index of 28.7 (overweight). Although 39% of participants were unaware of their CRC risk status, 30.9% indicated they were already making changes to reduce their risk. Although all respondents were significantly risk- and cost-averse, the latent class analysis identified 3 segments (classes): 1. Class 1 (26.8%) significantly favored phone or email support for a lifestyle change, a 17-month testing interval, and noninvasive testing. 2. Class 2 (48.4%) preferred the status quo. 3. Class 3 (24.7%) significantly favored further risk reduction and invasive testing.

CONCLUSIONS

This is the first documented preference study focusing on postpolypectomy surveillance offering lifestyle interventions. Although current care is strongly preferred, risk and cost aversion are important for participants. Latent class analysis shows that some respondents are willing to change diet and lifestyle behaviors, reflecting a teachable moment, with opportunities to personalize and optimize surveillance. Significant discordance between perceived and known risk of recurrence and limited recall of risk information provided within current practice suggest necessary improvements to surveillance programs.

Primary Care Provider Beliefs and Recommendations About Colorectal Cancer Screening in Four Healthcare Systems

Primary care provider's (PCP) perceptions of colorectal cancer screening test effectiveness and their recommendations for testing intervals influence patient screening uptake. Few large studies have examined providers' perceptions and recommendations, including their alignment with evidence suggesting comparable test effectiveness and guideline recommendations for screening frequency. Providers (n = 1,281) within four healthcare systems completed a survey in 2017-2018 regarding their perceptions of test effectiveness and recommended intervals for colonoscopy and fecal immunochemical testing (FIT) for patients ages 40-49, 50-74, and ≥75 years. For patients 50-74 (screening eligible), 82.9% of providers rated colonoscopy as very effective versus 59.6% for FIT, and 26.3% rated colonoscopy as more effective than FIT. Also, for this age group, 77.9% recommended colonoscopy every 10 years and 92.4% recommended FIT annually. For patients ages 40-49 and ≥75, more than one-third of providers believed the tests were somewhat or very effective, although >80% did not routinely recommend screening by either test for these age groups. Provider screening test interval recommendations generally aligned with colorectal cancer guidelines; however, 25% of providers believed colonoscopy was more effective than FIT for mortality reduction, which differs from some modeling studies that suggest comparable effectiveness. The latter finding may have implications for health systems where FIT is the dominant screening strategy. Only one-third of providers reported believing these screening tests were effective in younger and older patients (i.e., <50 and ≥75 years). Evidence addressing these beliefs may be relevant if cancer screening recommendations are modified to include older and/or younger patients.

Impact of Tailored Interventions on Receipt of a Preference-Concordant Colorectal Cancer Screening Test

Background. Individuals at average risk for colorectal cancer (CRC) have multiple test options. Preference for a specific test modality may affect decision making about CRC screening. The current study examined 1) the sociodemographic and health belief characteristics of average-risk participants with a test preference for stool blood test (SBT) versus those with a preference of colonoscopy, and following receipt of a tailored CRC screening intervention, 2) the percentage of participants who completed a preference-concordant CRC screening test, and 3) the sociodemographic, health care experience, and health belief characteristics and intervention group(s) associated with completion of a preference-concordant screening test. Methods. Participants (N = 603) were female, aged 50 to 75 years, at average CRC risk, not currently up-to-date with CRC screening recommendations, had Internet access, and were randomized to receive 1 of 3 tailored CRC screening promotion interventions. Multivariable logistic regression analyses were conducted. Results. Most women (64%) preferred SBT, whereas 36% preferred colonoscopy. There were significant differences in test preference by age, stage of change for the specific tests, perceived benefits of CRC screening, perceived barriers to both tests, and self-efficacy for colonoscopy. Two hundred thirty participants completed CRC screening at 6 months post-intervention. Of those, most (84%) completed a test concordant with their preference. Multivariable analyses revealed that compared with participants completing a preference-discordant test, those completing a preference-concordant test were older (P = 0.01), had health insurance (P < 0.05), and were in the phone counseling-only group (P < 0.01). Conclusions. High levels of completion of preference-concordant CRC screening can be achieved by educating average-risk patients about the multiple screening test options, soliciting their preferences, and offering testing that is concordant with their preference.

Socio-cognitive determinants of colorectal cancer screening uptake: An application of intervention mapping approach

Background: Fecal occult blood test (FOBT) is one of the common screening tests for colorectal cancer. This study was designed to determine the socio-cognitive determinants related to FOBT uptake for colorectal cancer screening based on intervention mapping (IM).

Methods: A total of 500 individuals aged over 50 years were randomly selected to participate in this study in Kermanshah, Iran, in 2016. Data were collected by interviews based on a questionnaire and analyzed by SPSS16 using bivariate correlation, linear, and logistic regression models.

Results: Of the 500 respondents, 468 (93.6%) signed the consent form and voluntarily participated in the study. Almost 11.1% of the participants had a history of FOBT uptake. Socio-cognitive variables accounted for 38% of the variation in the outcome measure of the intention to uptake FOBT. Perceived self-efficacy (OR = 3.345 & 95% CI: 1.342, 8.339), perceived susceptibility (OR = 2.204& 95% CI: 1.320, 3.680), attitude (OR = 1.674& 95% CI: 1.270, 2.137), and perceived severity (OR = 1.457& 95% CI: 0.954, 2.224) were the strongest predictors of fecal occult blood test uptake.

Conclusion: IM-based analysis of behavior may provide insights to design interventions for modifying individuals’ beliefs about the usefulness of FOBT uptake to prevent colorectal cancer.

Physician-office vs home uptake of colorectal cancer screening using FOBT/FIT among screening-eligible US adults

Background

Guidelines of the American Cancer Society and US Preventive Services Task Force specify that colorectal cancer (CRC) screening using guaiac‐based fecal occult blood test (FOBT)/fecal immunochemical test (FIT) should be done at home. We therefore examined the prevalence and correlates of CRC screening using FOBT/FIT in physicians' office vs at home.

Methods

Analysis of 9493 respondents 50‐75 years old from the Cancer Control Supplement of the 2015 National Health Interview Survey was conducted. Weighted multivariable logistic regression was used to identify the determinants of in‐office vs home use of FOBT/FIT for CRC screening.

Results

Of the overall sample of screening‐eligible adults (n = 9403), only 937 (10.4%) respondents underwent CRC screening using FOBT/FIT within the past year; among this screening population, 279 (28.3%) respondents were screened in‐office. We found that sociodemographic factors alone, not CRC risk factors, determined whether FOBT/FIT would be used in‐office or at home. Hispanics had greater odds of being screened in‐office using FOBT/FIT (aOR: 2.04; 95% CI: 1.05‐3.99). Compared with those 50‐59 years old, respondents 70‐75 years old were less likely to be screened in‐office using FOBT/FIT (aOR: 0.44, 95% CI: 0.25‐0.79). Similarly, individuals residing in the Western region of the country had lower odds of in‐office FOBT/FIT (aOR: 0.26; 95% CI: 0.11‐0.58).

Conclusion

Amid low overall uptake rates of FOBT/FIT in the United States, in‐physician office testing is high, indicative of a missed opportunity for effective screening and poor adherence of physicians to national guidelines. Sociodemographic factors are determinants of uptake of FOBT/FIT at home or in‐office and should be considered in designing interventions aimed at providers and the general population.

Amid low overall uptake rates of FOBT/FIT in the United States, in‐physician office testing is high, indicative of a missed opportunity for effective screening and poor adherence of physicians to national guidelines.

Utilization of Census Tract-Based Neighborhood Poverty Rates to Predict Non-adherence to Screening Colonoscopy

OBJECTIVES

Efforts to improve colorectal cancer (CRC) screening rates include recognizing predictors of colonoscopy non-adherence and identifying these high-risk patient populations. Past studies have focused on individual-level factors but few have evaluated the influence of neighborhood-level predictors. We sought to assess the effect of census tract-based neighborhood poverty rates on scheduled screening colonoscopy non-adherence.

METHODS

In this prospective observational cohort study, data from electronic medical records and appointment tracking software were collected in 599 patients scheduled to undergo outpatient CRC screening colonoscopy at two academic endoscopy centers between January 2011 and December 2012. Non-adherence was defined as failure to attend a colonoscopy appointment within 1 year of the date it was electronically scheduled. Neighborhood poverty rate was determined by matching patients' self-reported home address with their corresponding US census tract. Individual factors including medical comorbidities and prior appointment adherence behavior were also collected.

RESULTS

Overall, 17% (65/383) of patients were non-adherent to scheduled colonoscopy at 1-year follow-up. Neighborhood poverty rate was a significant predictor of non-adherence to scheduled screening colonoscopy in multivariate modeling (OR 1.53 per 10% increase in neighborhood poverty rate, 95% CI 1.21-1.95, p < 0.001). By incorporating the neighborhood poverty rate, screening colonoscopy non-adherence was 31% at the highest quartile compared to 14% at the lowest quartile of neighborhood poverty rates (p = 0.006).

CONCLUSIONS

Census tract-based neighborhood poverty rates can be used to predict non-adherence to scheduled screening colonoscopy. Targeted efforts to increase CRC screening efficiency and completion among patients living in high-poverty geographic regions could reduce screening disparities and improve utilization of endoscopy unit resources.

Screening initiation with FIT or colonoscopy: Post-hoc analysis of a pragmatic, randomized trial

Screening with FIT or colonoscopy can reduce CRC mortality. In our pragmatic, randomized trial of screening outreach over three years, patients annually received mailed FITs or colonoscopy invitations. We examined screening initiation after each mailing and crossover from the invited to other modality. Eligible patients (50-64 years, ≥1 primary-care visit before randomization, and no history of CRC) received mailed FIT kits (n = 2400) or colonoscopy invitations (n = 2400) from March 2013 through July 2016. Among those invited for colonoscopy, we used multinomial logistic regression to identify factors associated with screening initiation with colonoscopy vs. FIT vs. no screening after the first mailing. Most patients were female (61.8%) and Hispanic (48.9%) or non-Hispanic black (24.0%). Among those invited for FIT, 56.6% (n = 1359) initiated with FIT, whereas 3.3% (n = 78) crossed over to colonoscopy; 151 (15.7%) and 61 (7.7%) initiated with FIT after second and third mailings. Among those invited for colonoscopy, 25.5% (n = 613) initiated with colonoscopy whereas 18.8% (n = 452) crossed over to FIT; 112 (8.4%) and 48 (4.2%) initiated with colonoscopy after second and third mailings. Three or more primary-care visits prior to randomization were associated with initiating with colonoscopy (OR 1.49, 95% CI 1.17-1.91) and crossing over to FIT (OR 1.63, 95% CI 1.19-2.23). Although nearly half of patients initiated screening after the first mailing, few non-responders in either outreach group initiated after a second or third mailing. More patients invited to colonoscopy crossed over to FIT than those assigned to FIT crossed over to colonoscopy.

Use of Evidence-Based Interventions and Implementation Strategies to Increase Colorectal Cancer Screening in Federally Qualified Health Centers

While colorectal cancer (CRC) screening rates have been increasing in the general population, rates are considerably lower in Federally Qualified Health Centers (FQHCs), which serve a large proportion of uninsured and medically vulnerable patients. Efforts to screen eligible patients must be accelerated if we are to reach the national screening goal of 80% by 2018 and beyond. To inform this work, we conducted a survey of key informants at FQHCs in eight states to determine which evidence-based interventions (EBIs) to promote CRC screening are currently being used, and which implementation strategies are being employed to ensure that the interventions are executed as intended. One hundred and forty-eight FQHCs were invited to participate in the study, and 56 completed surveys were received for a response rate of 38%. Results demonstrated that provider reminder and recall systems were the most commonly used EBIs (44.6%) while the most commonly used implementation strategy was the identification of barriers (84.0%). The mean number of EBIs that were fully implemented at the centers was 2.4 (range 0-7) out of seven. Almost one-quarter of respondents indicated that their FQHCs were not using any EBIs to increase CRC screening. Full implementation of EBIs was correlated with higher CRC screening rates. These findings identify gaps as well as the preferences and needs of FQHCs in selecting and implementing EBIs for CRC screening.

Eliciting vulnerable patients' preferences regarding colorectal cancer screening: a systematic review

BACKGROUND

Patient preferences are important to consider in the decision-making process for colorectal cancer (CRC) screening. Vulnerable populations, such as racial/ethnic minorities and low-income, veteran, and rural populations, exhibit lower screening uptake. This systematic review summarizes the existing literature on vulnerable patient populations' preferences regarding CRC screening.

METHODS

We searched the CINAHL, PsycINFO, PubMed, Scopus, and Web of Science databases for articles published between January 1, 1996 and December 31, 2017. We screened studies for eligibility and systematically abstracted and compared study designs and outcomes.

RESULTS

A total of 43 articles met the inclusion criteria, out of 2,106 articles found in our search. These 43 articles were organized by the primary sub-population(s) whose preferences were reported: 27 report on preferences among racial/ethnic minorities, eight among low-income groups, six among veterans, and two among rural populations. The majority of studies (n=34) focused on preferences related to test modality. No single test modality was overwhelmingly supported by all sub-populations, although veterans seemed to prefer colonoscopy. Test attributes such as accuracy, sensitivity, cost, and convenience were also noted as important features. Furthermore, a preference for shared decision-making between vulnerable patients and providers was found.

CONCLUSION

The heterogeneity in study design, populations, and outcomes of the selected studies revealed a wide spectrum of CRC screening preferences within vulnerable populations. More decision aids and discrete choice experiments that focus on vulnerable populations are needed to gain a more nuanced understanding of how vulnerable populations weigh particular features of screening methods. Improved CRC screening rates may be achieved through the alignment of vulnerable populations' preferences with screening program design and provider practices. Collaborative decision-making between providers and vulnerable patients in preventive care decisions may also be important.

Colorectal Cancer Screening Preferences among Black and Latino Primary Care Patients

Colorectal cancer (CRC) screening rates in the U.S. have historically been lower among blacks and Latinos than whites. The advent of a new stool-based test, Cologuard, calls for research to determine which CRC screening test minority individuals might prefer. Ninety black and Latino patients who had undergone screening colonoscopy were personally educated about four CRC screening tests and subsequently asked about their test preference, attributes that influenced preference, and strength of preference. Cologuard (31.1 %) and colonoscopy (64.4 %) were preferred over computerized tomographic colonography and fecal immunochemical tests. Preference was influenced by distinct test attributes. Individuals who selected Cologuard over colonoscopy were more likely to be >60 and have greater strength of test preference. There was an overriding preference for Cologuard and colonoscopy among black and Latino individuals who had undergone screening colonoscopy. To further improve CRC screening in these populations, patient preferences should guide recommendations.

Understanding Cancer Worry Among Patients in a Community Clinic-Based Colorectal Cancer Screening Intervention Study

BACKGROUND

To reduce colorectal cancer (CRC) screening disparities, it is important to understand correlates of different types of cancer worry among ethnically diverse individuals.

OBJECTIVES

The current study examined the prevalence of three types of cancer worry (i.e., general cancer worry, CRC-specific worry, and worry about CRC test results) as well as sociodemographic and health-related predictors for each type of cancer worry.

METHODS

Participants were aged 50-75, at average CRC risk, nonadherent to CRC screening guidelines, and enrolled in a randomized controlled trial to increase CRC screening. Participants completed a baseline questionnaire assessing sociodemographics, health beliefs, healthcare experiences, and three cancer worry measures. Associations between study variables were examined with separate univariate and multivariable logistic regression models.

RESULTS

Responses from a total of 416 participants were used. Of these, 47% reported experiencing moderate-to-high levels of general cancer worry. Predictors of general cancer worry were salience and coherence (aOR = 1.1, 95% CI [1.0, 1.3]), perceived susceptibility (aOR = 1.2, 95% CI [1.1, 1.3), and social influence (aOR = 1.1, 95% CI [1.0, 0.1]). Fewer (23%) reported moderate-to-high levels of CRC-specific worry or CRC test worry (35%). Predictors of CRC worry were perceived susceptibility (aOR = 1.4, 95% CI [1.3, 1.6]) and social influence (aOR = 1.1, 95% CI [1.0, 1.2]); predictors of CRC test result worry were perceived susceptibility (aOR = 1.2, 95% CI [1.1, 1.3) and marital status (aOR = 2.0, 95% CI [1.1, 3.7] for married/partnered vs. single and aOR = 2.3, 95% CI [1.3, 4.1] for divorced/widowed vs. single).

DISCUSSION

Perceived susceptibility consistently predicted the three types of cancer worry, whereas other predictors varied between cancer worry types and in magnitude of association. The three types of cancer worry were generally predicted by health beliefs, suggesting potential malleability. Future research should include multiple measures of cancer worry and clear definitions of how cancer worry is measured.

Effect of a Digital Health Intervention on Receipt of Colorectal Cancer Screening in Vulnerable Patients: A Randomized Controlled Trial

BACKGROUND

Screening for colorectal cancer (CRC) reduces mortality, yet more than one third of age-eligible Americans are unscreened.

OBJECTIVE

To examine the effect of a digital health intervention, Mobile Patient Technology for Health-CRC (mPATH-CRC), on rates of CRC screening.

DESIGN

Randomized clinical trial. (ClinicalTrials.gov: NCT02088333).

SETTING

6 community-based primary care practices.

PARTICIPANTS

450 patients (223 in the mPATH-CRC group and 227 in usual care) scheduled for a primary care visit and due for routine CRC screening.

INTERVENTION

An iPad application that displays a CRC screening decision aid, lets patients order their own screening tests, and sends automated follow-up electronic messages to support patients.

MEASUREMENTS

The primary outcome was chart-verified completion of CRC screening within 24 weeks. Secondary outcomes were ability to state a screening preference, intention to receive screening, screening discussions, and orders for screening tests. All outcome assessors were blinded to randomization.

RESULTS

Baseline characteristics were similar between groups; 37% of participants had limited health literacy, and 53% had annual incomes less than $20 000. Screening was completed by 30% of mPATH-CRC participants and 15% of those receiving usual care (logistic regression odds ratio, 2.5 [95% CI, 1.6 to 4.0]). Compared with usual care, more mPATH-CRC participants could state a screening preference, planned to be screened within 6 months, discussed screening with their provider, and had a screening test ordered. Half of mPATH-CRC participants (53%; 118 of 223) "self-ordered" a test via the program.

LIMITATION

Participants were English speakers in a single health care system.

CONCLUSION

A digital health intervention that allows patients to self-order tests can increase CRC screening. Future research should identify methods for implementing similar interventions in clinical care.

PRIMARY FUNDING SOURCE

National Cancer Institute.

Patient Test Preference for Colorectal Cancer Screening and Screening Uptake in an Insured Urban Minority Population

The study examines the role of patient colorectal cancer (CRC) screening test preference and CRC screening uptake in an insured, urban minority population. Study subjects were enrolled in a randomized controlled trial to promote CRC screening. The interventions were educational, with an emphasis on colonoscopy screening. Subjects were 50+ years of age, fully insured for CRC screening, and out of compliance with current CRC screening recommendations. This paper includes those who answered a question about CRC screening test preference and indicated that they intended to receive such a test in the coming year (n = 453). CRC screening uptake was ascertained from medical claims data. Regardless of test preference, few received CRC screening (22.3 %). Those preferring the home stool test (HST) were less likely to get tested than those preferring a colonoscopy (16.6 vs 29.9 %, χ(2) = 9.9, p = .002). Preference for HST was more strongly associated with beliefs about colonoscopy than with knowledge about colonoscopy. In the context of an RCT emphasizing colonoscopy screening for CRC, patients expressing a preference for HST are at heightened risk of remaining unscreened. Colonoscopy should be recommended as the preferred CRC test, but HSTs should be accessible and encouraged for patients who are averse to colonoscopy.Clinical trials.gov: Identifier: NCT02392143.

The Role of Physician Recommendation in Colorectal Cancer Screening Receipt Among Immigrant Chinese Americans

Chinese Americans have low colorectal cancer (CRC) screening rates. It is unclear whether physicians should offer all CRC screening modalities (fecal occult blood test [FOBT], sigmoidoscopy, colonoscopy) to Chinese Americans to increase screening. Seven hundred and twenty-five Chinese Americans were asked in a survey if their physician had ever recommended CRC screening and to self-report receipt and type of CRC screening. Participants whose physician had recommended all CRC screening modalities were significantly more likely to report ever having screening (adjusted odds ratio 4.29, 95% CI 1.26-14.68) and being up-to-date (4.06, 95% CI 2.13-7.74) than those who reported that their physician only recommended FOBT. Participants who received a recommendation of only one type of screening did not report a significant difference in ever having or being up-to-date for screening. A potential strategy to increase CRC screening among Chinese Americans is for clinicians to recommend all available CRC screening modalities to each patient.

Effect of Colonoscopy Outreach vs Fecal Immunochemical Test Outreach on Colorectal Cancer Screening Completion: A Randomized Clinical Trial

IMPORTANCE

Mailed fecal immunochemical test (FIT) outreach is more effective than colonoscopy outreach for increasing 1-time colorectal cancer (CRC) screening, but long-term effectiveness may need repeat testing and timely follow-up for abnormal results.

OBJECTIVE

Compare the effectiveness of FIT outreach and colonoscopy outreach to increase completion of the CRC screening process (screening initiation and follow-up) within 3 years.

DESIGN, SETTING, AND PARTICIPANTS

Pragmatic randomized clinical trial from March 2013 to July 2016 among 5999 participants aged 50 to 64 years who were receiving primary care in Parkland Health and Hospital System and were not up to date with CRC screenings.

INTERVENTIONS

Random assignment to mailed FIT outreach (n = 2400), mailed colonoscopy outreach (n = 2400), or usual care with clinic-based screening (n = 1199). Outreach included processes to promote repeat annual testing for individuals in the FIT outreach group with normal results and completion of diagnostic and screening colonoscopy for those with an abnormal FIT result or assigned to colonoscopy outreach.

MAIN OUTCOMES AND MEASURES

Primary outcome was screening process completion, defined as adherence to colonoscopy completion, annual testing for a normal FIT result, diagnostic colonoscopy for an abnormal FIT result, or treatment evaluation if CRC was detected. Secondary outcomes included detection of any adenoma or advanced neoplasia (including CRC) and screening-related harms (including bleeding or perforation).

RESULTS

All 5999 participants (median age, 56 years; women, 61.9%) were included in the intention-to-screen analyses. Screening process completion was 38.4% in the colonoscopy outreach group, 28.0% in the FIT outreach group, and 10.7% in the usual care group. Compared with the usual care group, between-group differences for completion were higher for both outreach groups (27.7% [95% CI, 25.1% to 30.4%] for the colonoscopy outreach group; 17.3% [95% CI, 14.8% to 19.8%] for FIT outreach group), and highest in the colonoscopy outreach group (10.4% [95% CI, 7.8% to 13.1%] for the colonoscopy outreach group vs FIT outreach group; P < .001 for all comparisons). Compared with usual care, the between-group differences in adenoma and advanced neoplasia detection rates were higher for both outreach groups (colonoscopy outreach group: 10.3% [95% CI, 9.5% to 12.1%] for adenoma and 3.1% [95% CI, 2.0% to 4.1%] for advanced neoplasia, P < .001 for both comparisons; FIT outreach group: 1.3% [95% CI, -0.1% to 2.8%] for adenoma and 0.7% [95% CI, -0.2% to 1.6%] for advanced neoplasia, P < .08 and P < .13, respectively), and highest in the colonoscopy outreach group (colonoscopy outreach group vs FIT outreach group: 9.0% [95% CI, 7.3% to 10.7%] for adenoma and 2.4% [95% CI, 1.3% to 3.3%] for advanced neoplasia, P < .001 for both comparisons). There were no screening-related harms in any groups.

CONCLUSIONS AND RELEVANCE

Among persons aged 50 to 64 years receiving primary care at a safety-net institution, mailed outreach invitations offering FIT or colonoscopy compared with usual care increased the proportion completing CRC screening process within 3 years. The rate of screening process completion was higher with colonoscopy than FIT outreach.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01710215.

Cultural and emotional determinants of cervical cancer screening among older Hispanic women

Older adults are at highest risk of cancer and yet have the lowest rates of cancer screening participation. Older minority adults bear the burden of cancer screening disparities leading to late stage cancer diagnoses. This investigation, utilization data from the 2008 wave of the Health and Retirement study examined the cultural and emotional factors thought to influence cervical cancer screening among older Hispanic women. We utilized logistic regression models to conduct the analyses. Findings indicate that the emotional factors were not significant but the cultural factor, time orientation was a significant predictor for older Hispanics' cervical cancer screening behaviors.

Effect of Combined Patient Decision Aid and Patient Navigation vs Usual Care for Colorectal Cancer Screening in a Vulnerable Patient Population: A Randomized Clinical Trial

Importance

Colorectal cancer (CRC) screening is underused, especially among vulnerable populations. Decision aids and patient navigation are potentially complementary interventions for improving CRC screening rates, but their combined effect on screening completion is unknown.

Objective

To determine the combined effect of a CRC screening decision aid and patient navigation compared with usual care on CRC screening completion.

Design, Setting, and Participants

In this randomized clinical trial, data were collected from January 2014 to March 2016 at 2 community health center practices, 1 in North Carolina and 1 in New Mexico, serving vulnerable populations. Patients ages 50 to 75 years who had average CRC risk, spoke English or Spanish, were not current with recommended CRC screening, and were attending primary care visits were recruited and randomized 1:1 to intervention or control arms.

Interventions

Intervention participants viewed a CRC screening decision aid in English or Spanish immediately before their clinician encounter. The decision aid promoted screening and presented colonoscopy and fecal occult blood testing as screening options. After the clinician encounter, intervention patients received support for screening completion from a bilingual patient navigator. Control participants viewed a food safety video before the encounter and otherwise received usual care.

Main Outcomes and Measures

The primary outcome was CRC screening completion within 6 months of the index study visit assessed by blinded medical record review.

Results

Characteristics of the 265 participants were as follows: their mean age was 58 years; 173 (65%) were female, 164 (62%) were Latino; 40 (15%) were white non-Latino; 61 (23%) were black or of mixed race; 191 (78%) had a household income of less than $20 000; 101 (38%) had low literacy; 75 (28%) were on Medicaid; and 91 (34%) were uninsured. Intervention participants were more likely to complete CRC screening within 6 months (68% vs 27%); adjusted-difference, 40 percentage points (95% CI, 29-51 percentage points). The intervention was more effective in women than in men (50 vs 21 percentage point increase, interaction P = .02). No effect modification was observed across other subgroups.

Conclusions and Relevance

A patient decision aid plus patient navigation increased the rate of CRC screening completion in compared with usual care invulnerable primary care patients.

Trial Registration

clinicaltrials.gov Identifier: NCT02054598.

Colorectal Cancer Screening in Vulnerable Patients: Promoting Informed and Shared Decisions

INTRODUCTION

Low-income, low-literacy, limited English-proficient populations have low colorectal cancer (CRC) screening rates and experience poor patient-provider communication and decision-making processes around screening. The purpose of this study was to test the effect of a CRC screening decision aid on screening-related communication and decision making in primary care visits.

STUDY DESIGN

RCT with data collected from patients at baseline and immediately after the provider encounter.

SETTING/PARTICIPANTS

Patients aged 50-75 years, due for CRC screening, were recruited from two safety net clinics in North Carolina and New Mexico (data collection, January 2014-September 2015; analysis, 2015).

INTERVENTION

Participants viewed a CRC screening decision aid or a food safety (control) video immediately before their provider encounter.

MAIN OUTCOME MEASURES

CRC screening-related knowledge, discussion, intent, test preferences, and test ordering.

RESULTS

The study population (N=262) had a mean age of 58.3 years and was 66% female, 61% Latino, 17% non-Latino black, and 16% non-Latino white. Among Latino participants, 71% preferred Spanish. Compared with controls, intervention participants had greater screening-related knowledge (on average 4.6 vs 2.8 of six knowledge items correct, adjusted difference [AD]=1.8, 95% CI=1.5, 2.1) and were more likely to report screening discussion (71.0% vs 45.0%, AD=26.1%, 95% CI=14.3%, 38.0%) and high screening intent (93.1% vs 84.7%, AD=9.0%, 95% CI=2.0%, 16.0%). Intervention participants were more likely to indicate a specific screening test preference (93.1% vs 68.0%, AD=26.5%, 95% CI=17.2%, 35.8%) and to report having a test ordered (56.5% vs 32.1%, AD=25.8%, 95% CI=14.4%, 37.2%).

CONCLUSIONS

Viewing a CRC screening decision aid before a primary care encounter improves knowledge and shared decision making around screening in a racially, ethnically, and linguistically diverse safety net clinic population.

TRIAL REGISTRATION

This study is registered at www.clinicaltrials.gov NCT02054598.

Using a hypothetical scenario to assess public preferences for colorectal surveillance following screening-detected, intermediate-risk adenomas: annual home-based stool test vs. triennial colonoscopy

BACKGROUND

To assess public preferences for colorectal cancer (CRC) surveillance tests for intermediate-risk adenomas, using a hypothetical scenario.

METHODS

Adults aged 45-54 years without CRC were identified from three General Practices in England (two in Cumbria, one in London). A postal survey was carried out during a separate study on preferences for different first-line CRC screening modalities (non- or full-laxative computed tomographic colonography, flexible sigmoidoscopy, or colonoscopy). Individuals were allocated at random to receive a pack containing information on one first-line test, and a paragraph describing CRC surveillance recommendations for people who are diagnosed with intermediate-risk adenomas during screening. All participants received a description of two surveillance options: annual single-sample, home-based stool testing (consistent with Faecal Immunochemical Tests; FIT) or triennial colonoscopy. Invitees were asked to imagine they had been diagnosed with intermediate-risk adenomas, and then complete a questionnaire on their surveillance preferences.

RESULTS

22.1 % (686/3,100) questionnaires were returned. 491 (15.8 %) were eligible for analysis. The majority of participants stated a surveillance preference for the stool test over colonoscopy (60.8 % vs 31.0 %; no preference: 8.1 %; no surveillance: 0.2 %). Women were more likely to prefer the stool test than men (66.7 % vs. 53.6 %; p = .011). The primary reason for preferring the stool test was that it would be done more frequently. The main reason to prefer colonoscopy was its superiority at finding polyps.

CONCLUSIONS

A majority of participants stated a preference for a surveillance test resembling FIT over colonoscopy. Future research should test whether this translates to greater adherence in a real surveillance setting.

TRIAL REGISTRATION

International Standard Randomised Controlled Trial Number registry, ISRCTN85697880 , prospectively registered on 25/04/2013.

Training primary care physicians to offer their patients faecal occult blood testing and colonoscopy for colorectal cancer screening on an equal basis: a pilot intervention with before-after and parallel group surveys

OBJECTIVES

Primary care physicians (PCPs) should prescribe faecal immunochemical testing (FIT) or colonoscopy for colorectal cancer screening based on their patient's values and preferences. However, there are wide variations between PCPs in the screening method prescribed. The objective was to assess the impact of an educational intervention on PCPs' intent to offer FIT or colonoscopy on an equal basis.

DESIGN

Survey before and after training seminars, with a parallel comparison through a mailed survey to PCPs not attending the training seminars.

SETTING

All PCPs in the canton of Vaud, Switzerland.

PARTICIPANTS

Of 592 eligible PCPs, 133 (22%) attended a seminar and 106 (80%) filled both surveys. 109 (24%) PCPs who did not attend the seminars returned the mailed survey.

INTERVENTION

A 2 h-long interactive seminar targeting PCP knowledge, skills and attitudes regarding offering a choice of colorectal cancer (CRC) screening options.

OUTCOME MEASURES

The primary outcome was PCP intention of having their patients screened with FIT and colonoscopy in equal proportions (between 40% and 60% each). Secondary outcomes were the perceived role of PCPs in screening decisions (from paternalistic to informed decision-making) and correct answer to a clinical vignette.

RESULTS

Before the seminars, 8% of PCPs reported that they had equal proportions of their patients screened for CRC by FIT and colonoscopy; after the seminar, 33% foresaw having their patients screened in equal proportions (p<0.001). Among those not attending, there was no change (13% vs 14%, p=0.8). Of those attending, there was no change in their perceived role in screening decisions, while the proportion responding correctly to a clinical vignette increased (88-99%, p<0.001).

CONCLUSIONS

An interactive training seminar increased the proportion of physicians with the intention to prescribe FIT and colonoscopy in equal proportions.

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.

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.

•

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

•

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.

A Risk Prediction Index for Advanced Colorectal Neoplasia at Screening Colonoscopy

OBJECTIVES

Eliciting patient preferences within the context of shared decision making has been advocated for colorectal cancer screening. Risk stratification for advanced colorectal neoplasia (ACN) might facilitate more effective shared decision making when selecting an appropriate screening option. Our objective was to develop and validate a clinical index for estimating the probability of ACN at screening colonoscopy.

METHODS

We conducted a cross-sectional analysis of 3,543 asymptomatic, mostly average-risk patients 50-79 years of age undergoing screening colonoscopy at two urban safety net hospitals. Predictors of ACN were identified using multiple logistic regression. Model performance was internally validated using bootstrapping methods.

RESULTS

The final index consisted of five independent predictors of risk (age, smoking, alcohol intake, height, and a combined sex/race/ethnicity variable). Smoking was the strongest predictor (net reclassification improvement (NRI), 8.4%) and height the weakest (NRI, 1.5%). Using a simplified weighted scoring system based on 0.5 increments of the adjusted odds ratio, the risk of ACN ranged from 3.2% (95% confidence interval (CI), 2.6-3.9) for the low-risk group (score ≤2) to 8.6% (95% CI, 7.4-9.7) for the intermediate/high-risk group (score 3-11). The model had moderate to good overall discrimination (C-statistic, 0.69; 95% CI, 0.66-0.72) and good calibration (P=0.73-0.93).

CONCLUSIONS

A simple 5-item risk index based on readily available clinical data accurately stratifies average-risk patients into low- and intermediate/high-risk categories for ACN at screening colonoscopy. Uptake into clinical practice could facilitate more effective shared decision-making for CRC screening, particularly in situations where patient and provider test preferences differ.

Decisional stage distribution for colorectal cancer screening among diverse, low-income study participants

Colorectal cancer (CRC) screening uptake among minorities and those with lower incomes is suboptimal. Behavioral interventions specifically tailored to these populations can increase screening rates and save lives. The Precaution Adoption Process Model (PAPM) allows assignment of a decisional stage for adoption of a behavior such as CRC screening. Here, we characterize the PAPM decisional stage distribution among 470 low income, racially and ethnically diverse study participants at intake into a behavioral intervention study designed to increase CRC screening uptake. We staged participants for stool blood test (SBT) and colonoscopy separately and used the highest stage for the two tests as the 'overall' stage for CRC screening. For SBT, sex, language (English versus Spanish) and doctor recommendation were significantly related to PAPM stage for CRC screening. For colonoscopy, language, education level, doctor recommendation and self-efficacy were related to stage. For overall CRC screening stage, all the variables associated with either SBT or colonoscopy, with the exception of language were significant. This study suggests attending to these key variables in designing interventions to promote CRC screening, particularly with respect to medically underserved populations.

Comparison of patient preferences for fecal immunochemical test or colonoscopy using the analytic hierarchy process

Background

In average-risk individuals aged 50 to 75 years, there is no difference in life-years gained when comparing colonoscopy every 10 years vs. annual fecal immunochemical testing (FIT) for colorectal cancer screening. Little is known about the preferences of patients when they have experienced both tests.

Methods

The study was conducted with 954 patients from the University of Iowa Hospital and Clinics during 2010 to 2011. Patients scheduled for a colonoscopy were asked to complete a FIT before the colonoscopy preparation. Following both tests, patients completed a questionnaire which was based on an analytic hierarchy process (AHP) decision-making model.

Results

In the AHP analysis, the test accuracy was given the highest priority (0.457), followed by complications (0.321), and test preparation (0.223). Patients preferred colonoscopy (0.599) compared with FIT (0.401) when considering accuracy; preferred FIT (0.589) compared with colonoscopy (0.411) when considering avoiding complications; and preferred FIT (0.650) compared with colonoscopy (0.350) when considering test preparation. The overall aggregated priorities were 0.517 for FIT, and 0.483 for colonoscopy, indicating patients slightly preferred FIT over colonoscopy. Patients’ preferences were significantly different before and after provision of detailed information on test features (p < 0.0001).

Conclusions

AHP analysis showed that patients slightly preferred FIT over colonoscopy. The information provided to patients strongly affected patient preference. Patients’ test preferences should be considered when ordering a colorectal cancer screening test.

The effects of tailoring knowledge acquisition on colorectal cancer screening self-efficacy

Interventions tailored to psychological factors such as personal and vicarious behavioral experiences can enhance behavioral self-efficacy but are complex to develop and implement. Information seeking theory suggests tailoring acquisition of health knowledge (without concurrent psychological factor tailoring) could enhance self-efficacy, simplifying the design of tailored behavior change interventions. To begin to examine this issue, the authors conducted exploratory analyses of data from a randomized controlled trial, comparing the effects of an experimental colorectal cancer screening intervention tailoring knowledge acquisition with the effects of a nontailored control on colorectal cancer screening knowledge and self-efficacy in 1159 patients comprising three ethnicity/language strata (Hispanic/Spanish, 23.4%, Hispanic/English, 27.2%, non-Hispanic/English, 49.3%) and 5 recruitment center strata. Adjusted for study strata, the mean postintervention knowledge score was significantly higher in the experimental group than in the control group. Adjusted experimental intervention exposure (B = 0.22, 95% CI [0.14, 0.30]), preintervention knowledge (B = 0.11, 95% CI [0.05, 0.16]), and postintervention knowledge (B = 0.03, 95% CI [0.01, 0.05]) were independently associated with subsequent colorectal cancer screening self-efficacy (p < .001 all associations). These exploratory findings suggest that tailoring knowledge acquisition may enhance self-efficacy, with potential implications for tailored intervention design, but this implication requires confirmation in studies specifically designed to examine this issue.

Implementation intentions and colorectal screening: a randomized trial in safety-net clinics

CONTEXT

Low-income and racial/ethnic minority populations experience disproportionate colorectal cancer (CRC) burden and poorer survival. Novel behavioral strategies are needed to improve screening rates in these groups.

BACKGROUND

The study aimed to test a theoretically based "implementation intentions" intervention for improving CRC screening among unscreened adults in urban safety-net clinics.

DESIGN

Randomized controlled trial.

SETTING/PARTICIPANTS

Adults (N=470) aged ≥50 years, due for CRC screening, from urban safety-net clinics were recruited.

INTERVENTION

The intervention (conducted in 2009-2011) was delivered via touchscreen computers that tailored informational messages to decisional stage and screening barriers. The computer then randomized participants to generic health information on diet and exercise (Comparison group) or "implementation intentions" questions and planning (Experimental group) specific to the CRC screening test chosen (fecal immunochemical test or colonoscopy).

MAIN OUTCOME MEASURES

The primary study outcome was completion of CRC screening at 26 weeks based on test reports (analysis conducted in 2012-2013).

RESULTS

The study population had a mean age of 57 years and was 42% non-Hispanic African American, 28% non-Hispanic white, and 27% Hispanic. Those receiving the implementation intentions-based intervention had higher odds (AOR=1.83, 95% CI=1.23, 2.73) of completing CRC screening than the Comparison group. Those with higher self-efficacy for screening (AOR=1.57, 95% CI=1.03, 2.39), history of asthma (AOR=2.20, 95% CI=1.26, 3.84), no history of diabetes (AOR=1.86, 95% CI=1.21, 2.86), and reporting they had never heard that "cutting on cancer" makes it spread (AOR=1.78, 95% CI=1.16, 2.72) were more likely to complete CRC screening.

CONCLUSIONS

The results of this study suggest that programs incorporating an implementation intentions approach can contribute to successful completion of CRC screening even among very low-income and diverse primary care populations. Future initiatives to reduce CRC incidence and mortality disparities may be able to employ implementation intentions in large-scale efforts to encourage screening and prevention behaviors.

Communication preference moderates the effect of a tailored intervention to increase colorectal cancer screening among African Americans

OBJECTIVE

Test the impact of tailoring CRC screening messages for African Americans (AAs) using novel theoretical variables and to examine moderating effect of communication preferences.

METHODS

Participants were randomized to receive two minimally tailored or two enhanced tailored print newsletters addressing CRC. The enhanced intervention was tailored on Self-Determination Theory and other novel psychological constructs. Minimal tailoring only used information available in the patient's EHR. The primary outcome was CRC screening based on EHR. Participants were AA members aged 50-74 of an integrated health care delivery system not up to date on CRC screening.

RESULTS

We enrolled 881 participants. CRC screening participation rates at 1-year follow up were 20.5% and 21.5% in the minimally and enhanced tailored groups, respectively. Communication preferences moderated the impact of the intervention. Specifically, among those with an autonomous communication preference, screening rates in the minimally and enhanced tailored groups were 17.1% and 25.9%, respectively, while no intervention effect was evident among those with a directive preference.

CONCLUSION

Future research is needed to explore the impact of communication preference tailoring for other health behaviors and among other populations.

PRACTICE IMPLICATIONS

Tailored communications should consider communication style preference to help guide the content and tone of messages.

Evaluation of the effect of decision support on the efficiency of primary care providers in the outpatient practice

Background: Clinical decision support (CDS) for primary care has been shown to improve delivery of preventive services. However, there is little evidence for efficiency of physicians due to CDS assistance. In this article, we report a pilot study for measuring the impact of CDS on the time spent by physicians for deciding on preventive services and chronic disease management. Methods: We randomly selected 30 patients from a primary care practice, and assigned them to 10 physicians. The physicians were requested to perform chart review to decide on preventive services and chronic disease management for the assigned patients. The patients assignment was done in a randomized crossover design, such that each patient received 2 sets of recommendations—one from a physician with CDS assistance and the other from a different physician without CDS assistance. We compared the physician recommendations made using CDS assistance, with the recommendations made without CDS assistance. Results: The physicians required an average of 1 minute 44 seconds, when they were they had access to the decision support system and 5 minutes when they were unassisted. Hence the CDS assistance resulted in an estimated saving of 3 minutes 16 seconds (65%) of the physicians’ time, which was statistically significant (P < .0001). There was no statistically significant difference in the number of recommendations. Conclusion: Our findings suggest that CDS assistance significantly reduced the time spent by physicians for deciding on preventive services and chronic disease management. The result needs to be confirmed by performing similar studies at other institutions.

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.

Understanding current racial/ethnic disparities in colorectal cancer screening in the United States: the contribution of socioeconomic status and access to care

BACKGROUND

Prior studies have shown racial/ethnic disparities in colorectal cancer (CRC) screening but have not provided a full national picture of disparities across all major racial/ethnic groups.

PURPOSE

To provide a more complete, up-to-date picture of racial/ethnic disparities in CRC screening and contributing socioeconomic and access barriers.

METHODS

Behavioral Risk Factor Surveillance System data from 2010 were analyzed in 2013. Hispanic/Latino participants were stratified by preferred language (Hispanic-English versus Hispanic-Spanish). Non-Hispanics were categorized as White, Black, Asian, Native Hawaiian/Pacific Islander, or American Indian/Alaska Native. Sequential regression models estimated adjusted relative risks (RRs) and the degree to which SES and access to care explained disparities.

RESULTS

Overall, 59.6% reported being up-to-date on CRC screening. Self-reported CRC screening was highest in the White (62.0%) racial/ethnic group; followed by Black (59.0%); Native Hawaiian/Pacific Islander (54.6%); Hispanic-English (52.5%); American Indian/Alaska Native (49.5%); Asian (47.2%); and Hispanic-Spanish (30.6%) groups. Adjustment for SES and access partially explained disparities between Whites and Hispanic-Spanish (final relative risk [RR]=0.76, 95% CI=0.69, 0.83); Hispanic-English (RR=0.94, 95% CI=0.91, 0.98); and American Indian/Alaska Native (RR=0.91, 95% CI=0.85, 0.97) groups. The RR of screening among Asians was unchanged after adjustment for SES and access (0.78, p<0.001). After full adjustment, screening rates were not significantly different among Whites, Blacks, or Native Hawaiian/Pacific Islanders.

CONCLUSIONS

Large racial/ethnic disparities in CRC screening persist, including substantial differences between English-speaking versus Spanish-speaking Hispanics. Disparities are only partially explained by SES and access to care. Future studies should explore the low rate of screening among Asians and how it varies by racial/ethnic subgroup and language.

Uptake and positive predictive value of fecal occult blood tests: A randomized controlled trial

OBJECTIVE

The aim of this study is to compare the uptake of three mailed high-sensitivity fecal occult blood tests (FOBTs).

METHODS

We conducted a parallel 3-arm randomized controlled trial in an integrated healthcare delivery system in Washington State. From January 2010 through February 2011, automated data were used to identify potentially eligible patients aged 50-74 due for colorectal cancer screening. Participants were mailed one of three FOBT kits (1-sample OC-Auto® fecal immunochemical test [FIT], 2-sample InSure® FIT, or 3-sample guaiac Hemoccult SENSA®), instructions, and a postage-paid return envelope. We performed a modified intent-to-treat analysis with return of any FOBT within 6 months of randomization as the primary outcome.

RESULTS

Of the 9922 people invited, 2873 returned surveys, 2263 were randomized, and 2234 were analyzed. FOBTs were returned by 1431 participants. At 6 months post-randomization, the proportions screened by any FOBT were 0.69 (95% confidence interval [CI] 0.66-0.72) for the OC-Auto arm, 0.64 (95% CI: 0.61-0.68) for the InSure arm, and 0.61 (95% CI: 0.58-0.65) for the Hemoccult SENSA arm (P<0.001 for any difference). Pairwise comparisons showed significant differences between the OC-Auto group and each of the other groups after correction for multiple comparisons.

CONCLUSION

Uptake of mailed FOBT kits varies by kit type.

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.

Shared decision-making about colorectal cancer screening: a conceptual framework to guide research

OBJECTIVE

To develop a conceptual framework to guide research on shared decision-making about colorectal cancer (CRC) screening among persons at average risk and their providers.

METHODS

Based upon a comprehensive review of empirical literature and relevant theories, a conceptual framework was developed that incorporated patient characteristics, cultural beliefs, provider/health care system variables, health belief/knowledge/stage of adoption variables, and shared decision-making between patients and providers that may predict behavior. Relationships among concepts in the framework, shared decision-making process and outcomes, and CRC screening behavior were proposed. Directions for future research were presented.

RESULTS

Many of the concepts in the proposed framework have been examined in prior research. However, these elements have not been combined previously to explain shared decision-making about CRC screening.

CONCLUSION

Research is needed to test the proposed relationships and hypotheses and to refine the framework.

PRACTICE IMPLICATIONS

Findings from future research guided by the proposed framework may inform clinical practice to facilitate shared decision-making about CRC screening.

Design of a randomized controlled trial to assess the comparative effectiveness of a multifaceted intervention to improve adherence to colorectal cancer screening among patients cared for in a community health center

Background

Colorectal cancer (CRC) is common and leads to significant morbidity and mortality. Although screening with fecal occult blood testing (FOBT) or endoscopy has been shown to decrease CRC mortality, screening rates remain suboptimal. Screening rates are particularly low for people with low incomes and members of underrepresented minority groups. FOBT should be done annually to detect CRC early and to reduce CRC mortality, but this often does not occur. This paper describes the design of a multifaceted intervention to increase long-term adherence to FOBT among poor, predominantly Latino patients, and the design of a randomized controlled trial (RCT) to test the efficacy of this intervention compared to usual care.

Methods

In this RCT, patients who are due for repeat FOBT are identified in the electronic health record (EHR) and randomized to receive either usual care or a multifaceted intervention. The usual care group includes multiple point-of-care interventions (e.g., standing orders, EHR reminders), performance measurement, and financial incentives to improve CRC screening rates. The intervention augments usual care through mailed CRC screening test kits, low literacy patient education materials, automated phone and text message reminders, in-person follow up calls from a CRC Screening Coordinator, and communication of results to patients along with a reminder card highlighting when the patient is next due for screening. The primary outcome is completion of FOBT within 6 months of becoming due.

Discussion

The main goal of the study is to determine the comparative effectiveness of the intervention compared to usual care. Additionally, we want to assess whether or not it is possible to achieve high rates of adherence to CRC screening with annual FOBT, which is necessary for reducing CRC mortality. The intervention relies on technology that is increasingly widespread and declining in cost, including EHR systems, automated phone and text messaging, and FOBTs for CRC screening. We took this approach to ensure generalizability and allow us to rapidly disseminate the intervention through networks of community health centers (CHCs) if the RCT shows the intervention to be superior to usual care.

Trial registration

ClinicalTrials.gov NCT01453894

An automated intervention with stepped increases in support to increase uptake of colorectal cancer screening: a randomized trial

BACKGROUND

Screening decreases colorectal cancer (CRC) incidence and mortality, yet almost half of age-eligible patients are not screened at recommended intervals.

OBJECTIVE

To determine whether interventions using electronic health records (EHRs), automated mailings, and stepped increases in support improve CRC screening adherence over 2 years.

DESIGN

4-group, parallel-design, randomized, controlled comparative effectiveness trial with concealed allocation and blinded outcome assessments. (ClinicalTrials.gov: NCT00697047)

SETTING

21 primary care medical centers.

PATIENTS

4675 adults aged 50 to 73 years not current for CRC screening.

INTERVENTION

Usual care, EHR-linked mailings ("automated"), automated plus telephone assistance ("assisted"), or automated and assisted plus nurse navigation to testing completion or refusal ("navigated"). Interventions were repeated in year 2.

MEASUREMENTS

The proportion of participants current for screening in both years, defined as colonoscopy or sigmoidoscopy (year 1) or fecal occult blood testing (FOBT) in year 1 and FOBT, colonoscopy, or sigmoidoscopy (year 2).

RESULTS

Compared with those in the usual care group, participants in the intervention groups were more likely to be current for CRC screening for both years with significant increases by intensity (usual care, 26.3% [95% CI, 23.4% to 29.2%]; automated, 50.8% [CI, 47.3% to 54.4%]; assisted, 57.5% [CI, 54.5% to 60.6%]; and navigated, 64.7% [CI, 62.5% to 67.0%]; P < 0.001 for all pair-wise comparisons). Increases in screening were primarily due to increased uptake of FOBT being completed in both years (usual care, 3.9% [CI, 2.8% to 5.1%]; automated, 27.5% [CI, 24.9% to 30.0%]; assisted, 30.5% [CI, 27.9% to 33.2%]; and navigated, 35.8% [CI, 33.1% to 38.6%]).

LIMITATION

Participants were required to provide verbal consent and were more likely to be white and to participate in other types of cancer screening, limiting generalizability.

CONCLUSION

Compared with usual care, a centralized, EHR-linked, mailed CRC screening program led to twice as many persons being current for screening over 2 years. Assisted and navigated interventions led to smaller but significant stepped increases compared with the automated intervention only. The rapid growth of EHRs provides opportunities for spreading this model broadly.