Inadequate Systems to Support Breast and Cervical Cancer Screening in Primary Care Practice

Background

Despite substantial resources devoted to cancer screening nationally, the availability of clinical practice-based systems to support screening guidelines is not known.

Objective

To characterize the prevalence and correlates of practice-based systems to support breast and cervical cancer screening, with a focus on the patient-centered medical home (PCMH).

Design

Web and mail survey of primary care providers conducted in 2014. The survey assessed provider (gender, training) and facility (size, specialty training, physician report of National Committee for Quality Assurance (NCQA) PCMH recognition, and practice affiliation) characteristics. A hierarchical multivariate analysis clustered by clinical practice was conducted to evaluate characteristics associated with the adoption of practice-based systems and technology to support guideline-adherent screening.

Participants

Primary care physicians in family medicine, general internal medicine, and obstetrics and gynecology, and nurse practitioners or physician assistants from four clinical care networks affiliated with PROSPR (Population-based Research Optimizing Screening through Personalized Regimens) consortium research centers.

Main Measures

The prevalence of routine breast cancer risk assessment, electronic health record (EHR) decision support, comparative performance reports, and panel reports of patients due for routine screening and follow-up.

Key Results

There were 385 participants (57.6 % of eligible). Forty-seven percent (47.0 %) of providers reported NCQA recognition as a PCMH. Less than half reported EHR decision support for breast (48.8 %) or cervical cancer (46.2 %) screening. A minority received comparative performance reports for breast (26.2 %) or cervical (19.7 %) cancer screening, automated reports of patients overdue for breast (18.7 %) or cervical (16.4 %) cancer screening, or follow-up of abnormal breast (18.1 %) or cervical (17.6 %) cancer screening tests. In multivariate analysis, reported NCQA recognition as a PCMH was associated with greater use of comparative performance reports of guideline-adherent breast (OR 3.23, 95 % CI 1.58–6.61) or cervical (OR 2.56, 95 % CI 1.32–4.96) cancer screening and automated reports of patients overdue for breast (OR 2.19, 95 % CI 1.15–41.7) or cervical (OR. 2.56, 95 % CI 1.26–5.26) cancer screening.

Conclusions

Providers lack systems to support breast and cervical cancer screening. Practice transformation toward a PCMH may support the adoption of systems to achieve guideline-adherent cancer screening in primary care settings.

     

Race/Ethnicity and Adoption of a Population Health Management Approach to Colorectal Cancer Screening in a Community-Based Healthcare System

Background

Screening outreach programs using population health management principles offer services uniformly to all eligible persons, but racial/ethnic colorectal cancer (CRC) screening patterns in such programs are not well known.

Objective

To examine the association between race/ethnicity and the receipt of CRC screening and timely follow-up of positive results before and after implementation of a screening program.

Design

Retrospective cohort study of screen-eligible individuals at the Kaiser Permanente Northern California community-based integrated healthcare delivery system (2004–2013).

Subjects

A total of 868,934 screen-eligible individuals 51–74 years of age at cohort entry, which included 662,872 persons in the period before program implementation (2004–2006), 654,633 during the first 3 years after implementation (2007–2009), and 665,268 in the period from 4 to 7 years (2010–2013) after program implementation.

Intervention

A comprehensive system-wide long-term effort to increase CRC that included leadership alignment, goal-setting, and quality assurance through a PHM approach, using mailed fecal immunochemical testing (FIT) along with offering screening at office visits.

Main Measures

Differences over time and by race/ethnicity in up-to-date CRC screening (overall and by test type) and timely follow-up of a positive screen. Race/ethnicity categories included non-Hispanic white, non-Hispanic black, Hispanic/Latino, Asian/Pacific Islander, Native American, and multiple races.

Key Results

From 2004 to 2013, age/sex-adjusted CRC screening rates increased in all groups, including 35.2 to 81.1 % among whites and 35.6 to 78.0 % among blacks. Screening rates among Hispanics (33.1 to 78.3 %) and Native Americans (29.4 to 74.5 %) remained lower than those for whites both before and after program implementation. Blacks, who had slightly higher rates before program implementation (adjusted rate ratio [RR]?=?1.04, 99 % CI: 1.02–1.05), had lower rates after program implementation (RR for period from 4 to 7 years?=?0.97, 99 % CI: 0.96–0.97). There were also substantial improvements in timely follow-up of positive screening results.

Conclusions

In this screening program using core PHM principles, CRC screening increased markedly in all racial/ethnic groups, but disparities persisted for some groups and developed in others, which correlated with levels of adoption of mailed FIT.

     

Association Between Primary Care Visits and Colorectal Cancer Screening Outcomes in the Era of Population Health Outreach

Background

Population outreach strategies are increasingly used to improve colorectal cancer (CRC) screening. The influence of primary care on cancer screening in this context is unknown.

Objective

To assess associations between primary care provider (PCP) visits and receipt of CRC screening and colonoscopy after a positive fecal immunochemical (FIT) or fecal occult blood test (FOBT).

Design

Population-based cohort study.

Participants

A total of 968,072 patients ages 50–74 years who were not up to date with CRC screening in 2011 in four integrated healthcare systems (three with screening outreach programs using FIT kits) in the Population-Based Research Optimizing Screening through Personalized Regimens (PROSPR) consortium.

Measures

Demographic, clinical, PCP visit, and CRC screening data were obtained from electronic health records and administrative databases. We examined associations between PCP visits in 2011 and receipt of FIT/FOBT, screening colonoscopy, or flexible sigmoidoscopy (CRC screening) in 2012 and follow-up colonoscopy within 3 months of a positive FIT/FOBT in 2012. We used multivariable logistic regression and propensity score models to adjust for confounding.

Results

Fifty-eight percent of eligible patients completed a CRC screening test in 2012, most by FIT. Those with a greater number of PCP visits had higher rates of CRC screening at all sites. Patients with ≥1 PCP visit had nearly twice the adjusted-odds of CRC screening (OR?=?1.88, 95 % CI: 1.86–1.89). Overall, 79.6 % of patients with a positive FIT/FOBT completed colonoscopy within 3 months. Patients with ≥1 PCP visit had 30 % higher adjusted odds of completing colonoscopy after positive FIT/FOBT (OR?=?1.30; 95 % CI: 1.22–1.40).

Conclusions

Patients with a greater number of PCP visits had higher rates of both incident CRC screening and colonoscopy after positive FIT/FOBT, even in health systems with active population health outreach programs. In this era of virtual care and population outreach, primary care visits remain an important mechanism for engaging patients in cancer screening.

     

Receipt of Cancer Screening Is a Predictor of Life Expectancy

Background

Obtaining cancer screening on patients with limited life expectancy has been proposed as a measure for low quality care for primary care physicians (PCPs). However, administrative data may underestimate life expectancy in patients who undergo screening.

Objective

To determine the association between receipt of screening mammography or PSA and overall survival.

Design

Retrospective cohort study from 1/1/1999 to 12/31/2012. Receipt of screening was assessed for 2001–2002 and survival from 1/1/2003 to 12/31/2012. Life expectancy was estimated as of 1/1/03 using a validated algorithm, and was compared to actual survival for men and women, stratified by receipt of cancer screening.

Participants

A 5 % sample of Medicare beneficiaries aged 69–90 years as of 1/1/2003 (n?=?906,723).

Interventions

Receipt of screening mammography in 2001–2002 for women, or a screening PSA test in 2002 for men.

Main Measures

Survival from 1/1/2003 through 12/31/2012.

Key Results

Subjects were stratified by life expectancy based on age and comorbidity. Within each stratum, the subjects with prior cancer screening had actual median survivals higher than those who were not screened, with differences ranging from 1.7 to 2.1 years for women and 0.9 to 1.1 years for men. In a Cox model, non-receipt of screening in women had an impact on survival (HR?=?1.52; 95 % CI?=?1.51, 1.54) similar in magnitude to a diagnosis of complicated diabetes or heart failure, and was comparable to uncomplicated diabetes or liver disease in men (HR?=?1.23; 1.22, 1.25).

Conclusions

Receipt of cancer screening is a powerful marker of health status that is not captured by comorbidity measures in administrative data. Because life expectancy algorithms using administrative data underestimate the life expectancy of patients who undergo screening, they can overestimate the problem of cancer screening in patients with limited life expectancy.

     

Navigating Language Barriers: A Systematic Review of Patient Navigators’ Impact on Cancer Screening for Limited English Proficient Patients

OBJECTIVES

To systematically review the literature on the impact of patient navigators on cancer screening for limited English proficient (LEP) patients.

DATA SOURCES

Electronic databases (PubMed, PsycINFO via OVID, Web of Science, Cochrane, EMBASE, and Scopus) through 8 May 2015.

ELIGIBILITY CRITERIA

Articles in this review had: (1) a study population of LEP patients eligible for breast, cervical or colorectal cancer screenings, (2) a patient navigator intervention to provide services prior to or during cancer screening, (3) a comparison of the patient navigator intervention to either a control group or another intervention, and (4) language-specific outcomes related to the patient navigator intervention.

STUDY APPRAISAL

We assessed the quality of the articles using the Downs and Black Scale.

RESULTS

Fifteen studies met the inclusion criteria and evaluated the screening rates for breast, colorectal, and cervical cancer in 15 language populations. Fourteen studies resulted in improved screening rates for LEP patients between 7 and 60 %. There was great variability in the patient navigation interventions evaluated. Training received by navigators was not reported in nine of the studies and no studies assessed the language skills of the patient navigators in English or the target language.

LIMITATIONS

This study is limited by the variability in study designs and limited reporting on patient navigator interventions, which reduces the ability to draw conclusions on the full effect of patient navigators.

CONCLUSIONS

Overall, we found evidence that navigators improved screening rates for breast, cervical and colorectal cancer screening for LEP patients. Future studies should systematically collect data on the training curricula for navigators and assess their English and non-English language skills in order to identify ways to reduce disparities for LEP patients.

     

Downstream Breast Imaging Following Screening Mammography in Medicare Patients with Advanced Cancer: A Population-Based Study

Background

Screening tests are generally not recommended in patients with advanced cancer and limited life expectancy. Nonetheless, screening mammography still occurs and may lead to follow-up testing.

Objective

We assessed the frequency of downstream breast imaging following screening mammography in patients with advanced colorectal or lung cancer.

Design

Population-based study.

Participants

The study included continuously enrolled female fee-for-service Medicare beneficiaries ≥65 years of age with advanced colorectal (stage IV) or lung (stage IIIB-IV) cancer reported to a Surveillance, Epidemiology, and End Results (SEER) registry between 2000 and 2011.

Main Measures

We assessed the utilization of diagnostic mammography, breast ultrasound, and breast MRI following screening mammography. Logistic regression models were used to explore independent predictors of utilization of downstream tests while controlling for cancer type and patient sociodemographic and regional characteristics.

Key Results

Among 34,127 women with advanced cancer (23% colorectal; 77% lung cancer; mean age at diagnosis 75 years), 9% (n = 3159) underwent a total of 5750 screening mammograms. Of these, 11% (n = 639) resulted in at least one subsequent diagnostic breast imaging examination within 9 months. Diagnostic mammography was most common (9%; n = 532), followed by ultrasound (6%; n = 334) and MRI (0.2%; n = 14). Diagnostic mammography rates were higher in whites than African Americans (OR, 1.6; p <0.05). Higher ultrasound utilization was associated with more favorable economic status (OR, 1.8; p <0.05).

Conclusions

Among women with advanced colorectal and lung cancer, 9% continued screening mammography, and 11% of these screening studies led to at least one additional downstream test, resulting in costs with little likelihood of meaningful benefit.

     

Strukturierte onkologische Nachsorge

Background

Patients with cancer and recommendations for aftercare are increasing worldwide.

Objectives

Presentation of the current follow-up guidelines of selected gastrointestinal tumors.

Materials and methods

The current German S3 guidelines for colorectal cancer, pancreatic cancer, hepatocellular carcinoma, and gastric cancer are analyzed.

Results

The S3 guidelines for colorectal cancer and hepatocellular carcinoma favor structured aftercare. For a period of 2–5 years, a combination of case history, physical examination, imaging, endoscopy, and determination of tumor markers is recommended. Advocacy for structured aftercare for pancreatic or gastric cancer must be decided individually. In general, the follow-up time and interval should be adjusted to the complaints of the patient, regardless of the tumor type.

Conclusions

Structured aftercare makes sense and is already part in the monitoring of selected gastrointestinal tumors.

     

Breast,Colorectal and Prostate Cancer Screening for Cancer Survivors and Non-Cancer Patients in Community Practices

BACKGROUND

Cancer survivors have cancer surveillance and preventive screening needs that require monitoring. Little is known regarding their patterns of care in community primary care practices.

METHODS

Secondary analysis of 750 baseline patient surveys and medical record audits for patients ages 50+ years in 25 community-based primary care practices (

RESULTS

Patient self-reported screening rates for breast cancer (72%), colorectal cancer (81%) and prostate cancer (77%) were higher for cancer survivors compared to noncancer patients (69%, 67%, 53%, respectively). Screening rates documented in the primary care records were lower for all cancers. Cancer survivors were more likely than others to report having been screened for colorectal cancer (P?=?0.034). Male cancer survivors were more likely to report being screened for prostate cancer than those without cancer (P?=?0.020). There were no significant differences in either self-reported or medical record report of breast cancer screening rates among cancer survivors and noncancer patients.

CONCLUSIONS

Cancer survivors were more likely to self-report receipt of cancer screening than noncancer patients. Medical record reports of cancer screening were lower than self-reports for cancer survivors and noncancer patients. Identifying factors that affect cancer screening among cancer survivors is important and has implications for intervention design.

     

Metachronous colorectal cancer

Aim

In this study, we present our patients with metachronous colorectal cancer.

Patients and methods

In the period between 1990 and 2009, 670 patients with colorectal cancer were treated.

Results

Metachronous cancer was developed in 4 (0.6%) patients. The time interval between index and metachronous cancer was 28 months to 22 years (mean 146 months).

Conclusion

Metachronous colorectal cancer is a potential risk that proves the necessity of postoperative colonoscopic control of all patients with colorectal cancer.

     

Trends in Frequency and Management of Obstructing Colorectal Cancers in a Well-Defined Population

Background

Few population-based studies investigate obstructing colorectal cancers. This study was designed to describe trends in their frequency and management.

Methods

Data were obtained for 13,331 colorectal cancers registered by the population-based cancer registry of Burgundy, France, between the years 1976 and 2000.

Results

Obstructing cancers represented 8.3 percent of all colorectal cancers. This proportion was stable throughout the study. Resection for cure increased from 54.9 percent (1976–1980) to 71.4 percent (1996–2000; P?=?0.011). Using multivariate analysis, site of cancer and period of diagnosis were the only factors significantly associated to a curative resection. Postoperative mortality for obstructing colorectal cancers decreased from 32.6 percent (1976–80) to 15.2 percent (1996–2000; P?

Conclusion

The frequency of obstructing colorectal cancers has remained unchanged for 25 years. Operative mortality is still high, although some improvements have occurred. Efforts must be made to diagnose colorectal cancers before obstruction occurs. Mass screening represents a promising approach.

     

Utilization of breast cancer screening with magnetic resonance imaging in community practice

Background

Breast cancer screening with magnetic resonance imaging (MRI) may be a useful adjunct to screening mammography in high-risk women, but MRI uptake may be increasing rapidly among low- and average-risk women for whom benefits are unestablished. Comparatively little is known about use of screening MRI in community practice.

Objective

To assess relative utilization of MRI among women who do and do not meet professional society guidelines for supplemental screening, and describe utilization according to breast cancer risk indications.

Design

Prospective cohort study conducted between 2007 and 2014.

Participants

In five regional imaging registries participating in the Breast Cancer Surveillance Consortium (BCSC), 348,955 women received a screening mammogram, of whom 1499 underwent screening MRI.

Main measures

Lifetime breast cancer risk (< 20% or ≥ 20%) estimated by family history of two or more first-degree relatives, and Gail model risk estimates. Breast Imaging Reporting and Data System breast density and benign breast diseases also were assessed. Relative risks (RR) for undergoing screening MRI were estimated using Poisson regression.

Key results

Among women with < 20% lifetime risk, which does not meet professional guidelines for supplementary MRI screening, and no first-degree breast cancer family history, screening MRI utilization was elevated among those with extremely dense breasts [RR 2.2; 95% confidence interval (CI) 1.7–2.8] relative to those with scattered fibroglandular densities and among women with atypia (RR 7.4; 95% CI 3.9–14.3.) or lobular carcinoma in situ (RR 33.1; 95% CI 18.0–60.9) relative to women with non-proliferative disease. Approximately 82.9% (95% CI 80.8%–84.7%) of screening MRIs occurred among women who did not meet professional guidelines and 35.5% (95% CI 33.1–37.9%) among women considered at low-to-average breast cancer risk.

Conclusion

Utilization of screening MRI in community settings is not consistent with current professional guidelines and the goal of delivery of high-value care.

     

Loop-ileostomy reversal—patient-related characteristics influencing time to closure

Purpose

To identify factors associated with timing of stoma reversal after rectal cancer surgery in a large Swedish register-based cohort.

Methods

Three thousand five hundred sixty-four patients with rectal cancer who received a protective stoma during surgery in 2007–2013 were identified in the Swedish colorectal cancer register. Time to stoma reversal was evaluated over a follow-up period of one and a half years. Factors associated with timing of stoma reversal were analysed using Cox regression analysis. Reversal within 9 months (12 months if adjuvant chemotherapy) was considered latest expected time to closure.

Results

Stoma reversal was performed in 2954 (82.9%) patients during follow-up. Patients with post-secondary education had an increased chance for early stoma reversal (HR 1.13; 95% CI 1.02–1.25). Postoperative complications (0.67; 0.62–0.73), adjuvant chemotherapy (0.63; 0.57–0.69), more advanced cancer stage (stage III 0.74; 0.66–0.83 and stage IV 0.38; 0.32–0.46) and higher ASA score (0.80; 0.71–0.90 for ASA 3–4) were associated with longer time to reversal. Two thousand four hundred thirty-seven (68.4%) patients had stoma reversal within latest expected time to closure. Factors associated to decreased chance of timely reversal were more advanced cancer stage (stage III 0.64; 0.50–0.81 and stage IV 0.19; 0.13–0.27), postoperative complications (0.50; 0.42–0.59) and higher ASA score (0.77; 0.61–0.96 for ASA 3–4).

Conclusions

Patients with a high level of education had a higher chance of timely reversal but medical factors had a stronger association to time to reversal. Patients with advanced rectal cancer are at high risk for non-reversal and should be considered for permanent stoma.

     

Screening and Follow-Up Monitoring for Substance Use in Primary Care: An Exploration of Rural–Urban Variations

BACKGROUND

Rates of substance use in rural areas are close to those of urban areas. While recent efforts have emphasized integrated care as a promising model for addressing workforce shortages in providing behavioral health services to those living in medically underserved regions, little is known on how substance use problems are addressed in rural primary care settings.

OBJECTIVE

To examine rural–urban variations in screening and monitoring primary care- based patients for substance use problems in a state-wide mental health integration program.

DESIGN

This was an observational study using patient registry.

SUBJECTS

The study included adult enrollees (n?=?15,843) with a mental disorder from 133 participating community health clinics.

MAIN OUTCOMES

We measured whether a standardized substance use instrument was used to screen patients at treatment entry and to monitor symptoms at follow-up visits.

KEY RESULTS

While on average 73.6 % of patients were screened for substance use, follow-up on substance use problems after initial screening was low (41.4 %); clinics in small/isolated rural settings appeared to be the lowest (13.6 %). Patients who were treated for a mental disorder or substance abuse in the past and who showed greater psychiatric complexities were more likely to receive a screening, whereas patients of small, isolated rural clinics and those traveling longer distances to the care facility were least likely to receive follow-up monitoring for their substance use problems.

CONCLUSIONS

Despite the prevalent substance misuse among patients with mental disorders, opportunities to screen this high-risk population for substance use and provide a timely follow-up for those identified as at risk remained overlooked in both rural and urban areas. Rural residents continue to bear a disproportionate burden of substance use problems, with rural–urban disparities found to be most salient in providing the continuum of services for patients with substance use problems in primary care.

     

The Association Between Primary Source of Healthcare Coverage and Colorectal Cancer Screening Among US Veterans

Background

Colorectal cancer (CRC) is a deadly but largely preventable disease. Screening improves outcomes, but screening rates vary across healthcare coverage models. In the Veterans Health Administration (VA), screening rates are high; however, it is unknown how CRC screening rates compare for Veterans with other types of healthcare coverage.

Aims

To determine whether Veterans with Veteran-status-related coverage (VA, military, TRICARE) have higher rates of CRC screening than Veterans with alternate sources of healthcare coverage.

Methods

We conducted a cross-sectional analysis of Veterans 50–75 years from the 2014 Behavioral Risk Factor Surveillance System survey. We examined CRC screening rates and screening modalities. We performed multivariable logistic regression to identify the role of coverage type, demographics, and clinical factors on screening status.

Results

The cohort included 22,138 Veterans. Of these, 76.7% reported up-to-date screening. Colonoscopy was the most common screening modality (83.7%). Screening rates were highest among Veterans with Veteran-status-related coverage (82.3%), as was stool-based screening (10.8%). The adjusted odds of up-to-date screening among Veterans with Veteran-status-related coverage were 83% higher than among Veterans with private coverage (adjusted OR = 1.83, 95% CI = 1.52–2.22). Additional predictors of screening included older age, black race, high income, access to medical care, frequent medical visits, and employed or married status.

Conclusions

CRC screening rates were highest among Veterans with Veteran-status-related coverage. High CRC screening rates among US Veterans may be related to system-level characteristics of VA and military care. Insight to these system-level characteristics may inform mechanisms to improve CRC screening in non-VA settings.

     

Screening in spouses of colorectal cancer patients: a missed opportunity

Background

Spouses of colorectal cancer (CRC) patients could be at increased risk of developing CRC due to shared lifestyle habits with the patients which is a notable risk factor. This study explores the various issues surrounding CRC screening among these spouses.

Methods

A mixed method study comprising in-depth qualitative semi-structured interviews followed by structured quantitative questionnaire was administered to spouses who accompanied CRC patients during their appointments, from January 2016 to February 2017.

Results

Fifty spouses of CRC patients, median age of 60 (range, 41–82) years, were qualitatively interviewed but 5 of them did not complete the questionnaire. Only 26 (57.8%) of them were current with CRC screening. Data saturation was reached at the 48th participant.Four main themes emerged from the qualitative interviews. These included (i) adequacy of knowledge and attitudes about CRC screening, (ii) suboptimal public health promotion efforts of CRC screening, (iii) barriers of CRC screening, and (iv) need for mutual spousal support.From the questionnaires, spouses who were not current with CRC screening were more likely to report more barriers and have different cues to actions than those who are current. The majority of the spouses demonstrated high levels of knowledge on CRC, understood its severity and their susceptibility.

Conclusion

Spouses exhibit high levels of knowledge and awareness of the implications of CRC. Apart from addressing psychological issues during the acute phases, targeted interventions should be considered to improve their screening rates and to use them as advocates for CRC screening among family and community.

     

Follow-up Care Delivery Among Colorectal Cancer Survivors Most Often Seen by Primary and Subspecialty Care Physicians

Background

The Institute of Medicine has identified patients as a key source of information for assessing the quality of care.

Objective

To evaluate the association of physician specialty with the content and quality of follow-up cancer care.

Design and Participants

Three hundred three colorectal cancer (CRC) survivors in Northern California were surveyed 2–5 years post-diagnosis.

Measurements

Specialty of physician seen most often [primary care physician (PCP), oncologist, surgeon, or gastroenterologist]; other physician specialties seen; patient characteristics; content of visits; patient-centered quality of follow-up care (communication, coordination, nursing, and staff interactions).

Main Results

A minority (16%) of CRC survivors reported that the doctor they most often saw for follow-up cancer care was a PCP, while 60% saw an oncologist. Many CRC survivors (40%) saw >1 physician for follow-up cancer care. Survivors most often seen by PCPs were more likely to have three or more medical comorbidities (70% vs. 51%, p?=?0.012) than survivors seen by subspecialty physicians. Survivors seen by PCPs were less likely to report seeing a doctor for medical tests and more likely to report discussing disease prevention (82% vs. 64%, p?=?0.012) or diet (70% vs. 48%, p?=?0.005) with their doctor. There were no significant specialty differences in patient-centered quality of follow-up cancer care.

Conclusions

Cancer survivors’ assessment of the quality of care was similar across specialties, while the content of follow-up cancer care varied by physician specialty. These findings provide important information about the potential value of primary care and the need for coordination when delivering care to CRC survivors.

     

Frailty Assessment Predicts Acute Outcomes in Patients Undergoing Screening Colonoscopy

Background

Colonoscopy is associated with multiple adverse outcomes. With an aging population undergoing colorectal cancer screening, few modalities exist to assess the patient risk prior to colonoscopy. Frailty, the age-related decline in reserve and function across multiple organ systems, predicts poor surgical outcomes, but its role in endoscopy is unclear.

Aims

This prospective cohort study assesses the efficacy of frailty in predicting acute colonoscopy outcomes.

Methods

Participants aged ≥?50 years undergoing screening colonoscopy at a tertiary care center were recruited over 2 months ending in July 2017. Frailty was assessed using a validated 20-s upper-extremity frailty test, which measures the capacity of muscle performance. Demographic data, American Society of Anesthesiologists (ASA) status, and Charlson comorbidity index (CCI) were evaluated. Procedure-related adverse events and cardiopulmonary changes during and in the immediate post-procedure period were recorded. Adverse events were stratified into minor and major events. Chi-square and ANCOVA models were used in the analysis.

Results

Ninety-nine adults (mean age 62.8 years) were enrolled, among which 49 were non-frail and 50 were pre-frail/frail; 50 were female. Overall, 55 participants experienced a total of 87 adverse events. Frailty and ASA status were significantly associated with colonoscopy adverse events (p?=?0.01 and p?=?0.02, respectively). Age and CCI did not predict colonoscopy outcomes.

Conclusions

Compared to age and CCI, frailty status better predicts colonoscopy outcomes in older adults. Among adults undergoing colonoscopy, routine frailty screening should be considered for risk stratification. Additional prospective studies evaluating frailty measurements in endoscopy will further clarify its role in forecasting adverse events.

     

Cancer Risk Communication with Low Health Literacy Patients: A Continuing Medical Education Program

BACKGROUND

Low health literacy (HL) is an important risk factor for cancer health disparities.

OBJECTIVE

Describe a continuing medical education (CME) program to teach primary care physicians (PCP) cancer risk communication and shared decision-making (SDM) with low HL patients and baseline skills assessment.

DESIGN

Cluster randomized controlled trial in five primary care clinics in New Orleans, LA.

PARTICIPANTS

Eighteen PCPs and 73 low HL patients overdue for cancer screening.

INTERVENTION

Primary care physicians completed unannounced standardized patient (SP) encounters at baseline. Intervention physicians received SP verbal feedback; academic detailing to review cancer screening guidelines, red flags for identifying low HL, and strategies for effective counseling; and web-based tutorial of SP comments and checklist items hyperlinked to reference articles/websites.

MAIN MEASURES

Baseline PCP self-rated proficiency, SP ratings of physician general cancer risk communication and SDM skills, patient perceived involvement in care.

RESULTS

Baseline assessments show physicians rated their proficiency in discussing cancer risks and eliciting patient preference for treatment/decision-making as “very good”. SPs rated physician exploration of perceived cancer susceptibility, screening barriers/motivators, checking understanding, explaining screening options and associated risks/benefits, and eliciting preferences for screening as “satisfactory”. Clinic patients rated their doctor’s facilitation of involvement in care and information exchange as “good”. However, they rated their participation in decision-making as “poor”.

DISCUSSION

The baseline skills assessment suggests a need for physician training in cancer risk communication and shared decision making for patients with low HL. We are determining the effectiveness of teaching methods, required resources and long-term feasibility for a CME program.

     

Use of an Electronic Clinical Reminder for Brief Alcohol Counseling is Associated with Resolution of Unhealthy Alcohol Use at Follow-Up Screening

BACKGROUND/OBJECTIVE

Brief alcohol counseling is a foremost US prevention priority, but no health-care system has implemented it into routine care. This study evaluated the effectiveness of an electronic clinical reminder for brief alcohol counseling (“reminder”). The specific aims were to (1) determine the prevalence of use of the reminder and (2) evaluate whether use of the reminder was associated with resolution of unhealthy alcohol use at follow-up screening.

METHODS

The reminder was implemented in February 2004 in eight VA clinics where providers routinely used clinical reminders. Patients eligible for this retrospective cohort study screened positive on the AUDIT-C alcohol screening questionnaire (February 2004–April 2006) and had a repeat AUDIT-C during the 1–36 months of follow-up (mean 14.5). Use of the alcohol counseling clinical reminder was measured from secondary electronic data. Resolution of unhealthy alcohol use was defined as screening negative at follow-up with a ≥2-point reduction in AUDIT-C scores. Logistic regression was used to identify adjusted proportions of patients who resolved unhealthy alcohol use among those with and without reminder use.

RESULTS

Among 4,198 participants who screened positive for unhealthy alcohol use, 71% had use of the alcohol counseling clinical reminder documented in their medical records. Adjusted proportions of patients who resolved unhealthy alcohol use were 31% (95% CI 30–33%) and 28% (95% CI 25–30%), respectively, for patients with and without reminder use (p-value?=?0.031).

CONCLUSIONS

The brief alcohol counseling clinical reminder was used for a majority of patients with unhealthy alcohol use and associated with a moderate decrease in drinking at follow-up.