Colorectal cancer screening among users of county health centers and users of private physician practices

Identifying quality improvement targets to facilitate colorectal cancer screening completion

The colorectal cancer (CRC) screening process involves multiple interfaces (communication exchanges and transfers of responsibility for specific actions) among primary care and gastroenterology providers, laboratory, and administrative staff. After a retrospective electronic health record (EHR) analysis discovered substantial clinic variation and low CRC screening prevalence overall in an urban, integrated safety-net system, we launched a qualitative analysis to identify potential quality improvement targets to enhance fecal immunochemical test (FIT) completion, the system's preferred screening modality. Here, we report examination of organization-, clinic-, and provider-level interfaces over a three-year period (December 2011-October 2014). We deployed in parallel 3 qualitative data collection methods: (1) structured observation (90+ hours, 10 sites); (2) document analysis (n > 100); and (3) semi-structured interviews (n = 41) and conducted iterative thematic analysis in which findings from each method cross-informed subsequent data collection. Thematic analysis was guided by a conceptual model and applied deductive and inductive codes. There was substantial variation in protocols for distributing and returning FIT kits both within and across clinics. Providers, clinic and laboratory staff had differing access to important data about FIT results based on clinical information system used and this affected results reporting. Communication and coordination during electronic referrals for diagnostic colonoscopy was suboptimal particularly for co-morbid patients needing anesthesia clearance. Our multi-level approach elucidated organizational deficiencies not evident by quantitative analysis alone. Findings indicate potential quality improvement intervention targets including: (1) best-practices implementation across clinics; (2) detailed communication to providers about FIT results; and (3) creation of EHR alerts to resolve pending colonoscopy referrals before they expire.

Physician counseling on colorectal cancer screening and receipt of screening among Latino patients

BACKGROUND

Latinos have lower rates of colorectal cancer (CRC) screening and later stage diagnosis than Whites, which may be partially explained by physician communication factors.

OBJECTIVE

We assessed associations between patient-reported physician counseling regarding CRC screening and receipt of CRC screening among Latino primary care patients.

DESIGN

This was a cross-sectional telephone survey.

PARTICIPANTS

The participants of this study were Latino primary care patients 50 years of age or older, with one or more visits during the preceding year.

MAIN MEASURES

We developed patient-reported measures to assess whether physicians provided explanations of CRC risks and tests, elicited patients' barriers to CRC screening, were responsive to patients' concerns about screening, and encouraged patients to be screened. Outcomes were patient reports of receipt of endoscopy (sigmoidoscopy or colonoscopy) and fecal occult blood test (FOBT) within recommended guidelines.

KEY RESULTS

Of 817 eligible patients contacted, 505 (62 %) completed the survey; mean age was 61 years (SD 8.4), 69 % were women, and 53 % had less than high school education. Forty-six percent reported obtaining endoscopy (with or without FOBT), 13 % reported FOBT only, and 41 % reported no CRC screening. In bivariate analyses, physician explanations, elicitation of barriers, responsiveness to concerns, and greater encouragement for screening were associated with receipt of endoscopy (p < 0.001), and explanations (p < 0.05) and encouragement (p < 0.001) were associated with FOBT. Adjusting for covariates, physician explanations (OR = 1.27; 95 % CI 1.03, 1.58) and greater physician encouragement (OR = 6.74; 95 % CI 3.57, 12.72) were associated with endoscopy; patients reporting quite a bit/a lot of physician encouragement had six times higher odds of obtaining the FOBT as those reporting none/a little encouragement (OR = 6.54; 95 % CI 2.76, 15.48).

CONCLUSIONS

Among primarily lower-socioeconomic status Latino patients, the degree to which patients perceived that physicians encouraged CRC screening was more strongly associated with screening than with providing risk information, eliciting barriers, and responding to their concerns about screening.

System Strategies for Colorectal Cancer Screening at Federally Qualified Health Centers

Objectives. We assessed the protocols and system processes for colorectal cancer (CRC) screening at federally qualified health centers (FQHCs) in 4 midwestern states. Methods. We identified 49 FQHCs in 4 states. In January 2013, we mailed their medical directors a 49-item questionnaire about policies on CRC screening, use of electronic medical records, types of CRC screening recommended, clinic tracking systems, referrals for colonoscopy, and barriers to providing CRC. Results. Forty-four questionnaires (90%) were returned. Thirty-three of the respondents (75%) estimated the proportion of their patients up-to-date with CRC screening, with a mean of 35%. One major barrier to screening was inability to provide colonoscopy for patients with a positive fecal occult blood test (59%). The correlation of system strategies and estimated percentage of patients up-to-date with CRC screening was 0.43 (P = .01). Conclusions. CRC system strategies were associated with higher CRC screening rates. Implementing system strategies for CRC screening takes time and effort and is important to maintain, to help prevent, or to cure many cases of CRC, the second leading cause of cancer in the United States.

Perceptions of risk factors for colorectal cancer and colorectal cancer risk-related behaviors among current, ex-, and nonsmokers

Smoking significantly increases risk for colorectal cancer (CRC). We examined smokers' and nonsmokers' perceptions of behavioral factors for the increased risk of CRC and evaluated how these related to CRC screening. Self-reported questionnaire data were obtained from a random, average CRC risk sample of women and men (aged 50-75 years) during 2004. Smokers less frequently reported recent CRC screening than nonsmokers (p = 0.03). Smokers not adherent to screening less frequently agreed that smoking and alcohol consumption (both strongly linked to CRC) increased the risk for CRC (p values < 0.05) than nonsmokers. Notably, the number of concurrent CRC risk behaviors reported by smokers not adherent to CRC screening increased with the number of cigarettes smoked per day, identifying heavy smokers who do not screen as a subgroup most in need of intervention. Findings extend current understanding on processes underlying smokers' perceptions of risk for CRC and how these relate to screening utilization, which can guide provider efforts to improve CRC screening among smokers and reduce their CRC risk-related behaviors.

Body mass index and screening for colorectal cancer: gender and attitudinal factors

BACKGROUND

Overweight/obese women and men are at increased risk for colorectal cancer (CRC) incidence and mortality. Research examining body mass index (BMI) and CRC screening has had mixed results. A clearer understanding of the extent to which high-BMI subgroups are screened for CRC is needed to inform planning for CRC screening promotions targeting BMI.

METHODS

Data were obtained from a random, population-based sample of women and men at average-risk for CRC (aged 50-75 years) during 2004 (n = 1098). Multiple logistic regression analyses were conducted to evaluate whether BMI category was significantly associated with the probability of reporting recent CRC screening and with the probability of agreeing with statements denoting attitudes/perceptions about CRC and screening. Attitudes/perceptions about CRC and screening were evaluated as potential mediators and moderators of the association between BMI category and CRC screening.

RESULTS

After controlling for characteristics associated with CRC screening, overweight and obese women were each 40% less likely to have CRC screening than women with normal-BMI (OR = 0.6, 95% CI:0.4-0.9 and OR = 0.6, 95% CI:0.3-0.9). BMI category was unrelated to screening among men. Obese women (but not men) were less aware than normal-BMI women that obesity increased risk for CRC (OR = 0.5, 95% CI:0.3-0.9) and less worried about CRC (OR = 0.5, 95% CI:0.3-0.8). However, findings suggest that attitudes/perceptions about CRC and screening did not mediate or moderate the association between BMI category and CRC screening.

CONCLUSION

Overweight/obese women are at increased risk for CRC because of their greater BMI and their propensity not to screen for CRC. Study findings suggest that potentially modifiable perceptions, e.g., lack of awareness of risk for CRC and less worry about CRC, in this subgroup may not explain the relationship between BMI category and reduced screening.

Predictors of delayed-stage colorectal cancer: are we neglecting critical demographic information?

PURPOSE

We sought to distinguish roles of demographic variables and bowel segments as predictors of delayed versus early stage colorectal cancer in California.

METHODS

Demographic and anatomic variables for 66,806 colorectal cancers were extracted from the California Cancer Registry for 2004-2008 and analyzed using logistic regression as delayed versus early stage.

RESULTS

Odds ratios (OR) for binary stage categories comparing age <40 (OR=2.58; 95% CI=2.26-2.94), 40-49 (1.71; 95%=1.60-1.83) and 75+ (1.05; 1.02-1.09) relative to 50-74 years were computed. Compared with non-Hispanic whites, ORs for stage categories were: 1.05; 0.99-1.13 (non-Hispanic blacks), 1.08; 1.02-1.13 (Hispanics), and 1.05; 1.00-1.10 (Asian/others). Females had higher odds of delayed diagnosis (1.09; 1.06-1.13) than males. Descending ORs were measured for successively lower to highest socioeconomic status (SES) quintiles (OR 4:5=1.08; 1.03-1.14, OR 3:5=1.13; 1.08-1.19, OR 2:5=1.18; 1.12- 1.24, and OR 1:5=1.21; 1.14-1.28).

CONCLUSIONS

Younger and older than age 50-74; females; Hispanic ethnicity; bowel segment contrasts (right/left, proximal/distal, cecum plus appendix/distal), and lower SES were independent predictors of delayed diagnosis. Low SES was the most robust predictor of delayed diagnosis, independent of other covariates. Approximately 77% of delayed diagnoses were in non-Hispanic whites and Asian/others. These findings illustrate the value of a community SES index for targeting egalitarian colorectal cancer screening.

An academic medical center model for community colorectal cancer screening: the Centers for Disease Control and Prevention demonstration program experience

During 2005-2009, the Centers for Disease Control and Prevention funded five colorectal cancer (CRC) screening demonstration projects around the United States; only one was based in an academic medical center (AMC) rather than a health department. The Suffolk County Preventive Endoscopy Project (Project SCOPE) was a collaborative effort between Stony Brook University Medical Center (SBUMC) and the Suffolk County Department of Health Services. Project SCOPE's objective was to increase CRC screening among Suffolk County residents at least 50 years old who had inadequate or no insurance coverage for CRC screening. The demonstration application drew on the screening, diagnostic, and treatment resources of the AMC and the indigent populations using its outpatient clinics. Patients at 10 county health centers were a primary target for (previously inaccessible) colonoscopy screening. The project's organizational center was SBUMC's preventive medicine department, which was linked to SBUMC's large gastroenterology practice. The specific staffing, financial, and training issues faced by this project provide insights for others who are similarly interested in community engagement. During 40 months of screening, 800 indigent, culturally diverse patients were recruited, and they underwent colonoscopy. Challenges encountered included unreachable referred patients (425 patients; 28% of referrals) and medical ineligibility (e.g., symptomatic comorbid conditions). Pending legislation providing federal funding for a national program offers other AMCs the opportunity to adopt a model such as that proven feasible during Project SCOPE. The lessons learned may have broader application for fostering collaborative AMC partnerships and for enhancing recruitment and retention of participants through outreach.