Preventive services in veterans in relation to disability

Veterans with disabilities are at an increased risk of secondary impairments and may have difficulty accessing preventive services; accessibility may differ between Veterans who do and do not receive care at Department of Veterans Affairs (VA) facilities. We used data from the 2003 and 2004 Behavioral Risk Factor Surveillance System surveys to evaluate associations between disability and receipt of preventive services in Veterans. Veterans with a disability were more likely to have received influenza vaccinations (VA users and nonusers), pneumococcal vaccinations (VA nonusers: p < 0.001; VA users: p = 0.073), weight management counseling (VA nonusers: p < 0.001; male VA users: p < 0.001), lower gastrointestinal (GI) endoscopy (VA nonusers: 50-64 yr, p = 0.03; VA users: ≥65 yr, p = 0.085), mammography (VA users: p = 0.097), and serum cholesterol screening (VA nonusers: p < 0.001). Receipt was similar by disability status for fecal occult blood test (FOBT), lower GI endoscopy (VA users: 50-64 yr), human immunodeficiency virus testing, and cervical cancer screening. For no measure was there significantly lower receipt in those with versus without a disability, although there was marginal evidence in VA nonusers for overall colorectal cancer screening (i.e., lower GI endoscopy or FOBT: p = 0.063). Among Veterans, having a disability did not appear to be a barrier to receiving appropriate preventive care.     

Psychological distress as a barrier to preventive care in community-dwelling elderly in the United States

OBJECTIVE: The presence of psychologic distress in older adults may be associated with decreased adherence to recommended preventive-care services. This analysis aimed to measure the association between psychologic distress and adherence to United States Preventive Services Task Force (USPSTF)-recommended preventive-care services among older adults in the United States. DESIGN: We undertook a cross-sectional analysis of 3655 U.S. community-dwelling elderly from the 2001 Medical Expenditure Panel (MEPS) survey. MEASUREMENTS: The presence of psychologic distress was captured by the Mental Component Survey (MCS) of the SF-12. The receipt of 9 preventive care services were captured using MEPS: hypertension screening, influenza vaccination, fecal occult blood testing or sigmoidoscopy, mammography, clinical breast examination, cholesterol screening, prostate-specific antigen test, routine check-up, and dental checkup. RESULTS: Elderly reporting psychologic distress were 30% less likely than nondistressed elderly to receive influenza vaccination (OR = 0.70, 95% CI = 0.55-0.88) and 23% less likely to receive annual dental check-ups (OR= 0.77, 95% CI = 0.61-0.97). Women with psychologic distress were 27% less likely to receive a clinical breast examination (OR = 0.73, 95% CI = 0.57-0.94). Psychologic distress was not significantly associated with screening for hypertension, colon cancer, high cholesterol, or prostrate cancer, mammography, or routine check-ups. CONCLUSIONS: Elderly reporting psychologic distress were less likely to adhere to some, but not all, recommended preventive care guidelines. These results suggest that adherence to recommended preventive care guidelines may be improved, indirectly, by improving recognition and treatment of emotional health problems in the elderly.     

PS1-07: PSA Test Use in Primary Care

Background/Aims Some professional organizations advocate for PSA testing to screen for prostate cancer while others recommend against it. Regardless of position, each advocates for consideration of individual risk factors and for patients to consult with their physician when deciding. We describe men's use of PSA testing around the time of a periodic health examination (PHE), whether test use varies by patient risk factor status, and the extent to which PSA testing occurs following patient-physician discussion of PSA testing, prostate cancer, or both. Methods Physician and patient subjects were enrolled in an observational study of patient-physician decision making in primary care. Physicians were salaried, general internal and family medicine physicians. Patients were insured, aged 50-80 years, without a history of prostate cancer, and due for colorectal cancer screening at the time of an audio-recorded office visit between 2007-2009. Office visit recordings were joined with data from pre-visit patient surveys and automated laboratory data for the 6 prior and 8 subsequent weeks. Content of patient-physician discussions was coded with a structured coding worksheet (mean Cohen's Kappa = 0.77). Generalized estimating equations were used to evaluate associations among patient-physician screening-related talk, patient risk factors, and PSA use. Results Among N=161 study-eligible men, just over half (53%) presented with at least one risk factor: 11.2% family history; 29.2% aged 65+; and 21.2% black. Eighty-one percent used PSA testing around the time of their PHE (8.3% prior and 72.7% subsequent to visit). Test use did not differ significantly by risk factor status: family history, 94.4% vs. no family history, 79.4%, (p=0.13); aged 65+, 85.1% vs. aged <65, 79.8% (p=0.39); and blacks, 76.5% vs. whites, 82.7%(p=0.49). Prostate cancer, PSA testing, or both was mentioned during 82% of visits: 34.8% mentioned prostate cancer and 79.5% PSA testing. Among men tested subsequent to visit, these percents were 92.9%, 35.0% and 89.3%, respectively. Discussion PSA testing is common among men who schedule a PHE, regardless of risk factor status. Furthermore, 7% of men who receive PSA testing subsequent to their PHE, do so in absence of any mention of prostate cancer or PSA screening during the visit.     

Perceptions of colon cancer screening by stage of screening test adoption

Colorectal cancer remains the second leading cause of cancer death in the United States. To fully realize the benefits of early detection of colorectal cancer, screening rates must improve. This study assessed differences in beliefs (from the Health Belief Model) by stage of screening behavior adoption (based on the Transtheoretical Model of Change) as a foundation for intervention development. More people were in the precontemplation stage (not thinking about having the screening test) for fecal occult blood test and sigmoidoscopy versus contemplation (thinking about having the test) or action (adherent with screening). Those in precontemplation stage for fecal occult blood test had lower perceived risk than those in contemplation, lower perceived benefits than those in action, and higher barriers than both those in contemplation and those in action. For sigmoidoscopy stage of readiness, again, precontemplators had lower perceived risk and self-efficacy than contemplators and higher barriers than both contemplators and actors. Given the popularity of the transtheoretical model and the success of stage-based interventions to increase other cancer screening, especially mammography, we should begin to translate such effective interventions to colorectal cancer screening. As such, this study is one of very few to quantify beliefs across stages of colorectal cancer and identify significant differences across stages, laying the foundation for the development and testing of stage-based interventions.     

粪标本的综合检测在结直肠癌早期筛查中的意义

目的探索一种简便易行、无创的门诊早期筛查结直肠癌的有效方法。方法对2011年3月至2012年3月间从上海市闸北区9个社区医院选取150例结直肠癌高危人群以及40例健康体检者（对照组）分别进行粪标本的综合检测一粪潜血（FOBT）、粪钙卫蛋白（CPT）、粪微型染色体维持蛋白-2（MCM2）表达、粪K—ras基因突变并同时行结肠镜检查,评估粪标本的综合检测与早期诊断结直肠癌的关系。结果190例受检者中FOBT阳性者14例,阳性率为7．37％;CPT阳性者6例,阳性率为3．16％;K—ras均为阴性。共发现结直肠癌21例,检出率11．05％（21／190）,其中DukeA期11例（52．38％）,B期9例（42．86％）,C期1例（4．76％）;FOBT阳性者中结直肠癌检出率为78．57％（11／14）。其中发现病例组（21例）、高危组（129例）与对照组（40例）之间FOBT、MCM2表达差异显著（P〈0．01）,CPT均值没有显著差异（P〉0．05）。Logistic回归模型分析结果亦表明FOBT和MCM2对结直肠癌的筛查具有临床意义。结论联合检测粪FOBT、MCM2有助于在普查中发现结直肠癌高危人群,及早行结肠镜检查,有利于发现较早期结直肠癌,从而使疾病在可治愈的阶段得到根治。     

Colorectal cancer: risk factors and recommendations for early detection.

Spurred by mounting evidence that the detection and treatment of early-stage colorectal cancers and adenomatous polyps can reduce mortality, Medicare and some other payors recently authorized reimbursement for colorectal cancer screening in persons at average risk for this malignancy. A collaborative group of experts convened by the U.S. Agency for Health Care Policy and Research has recommended screening for average-risk persons over the age of 50 years using one of the following techniques: fecal occult blood testing each year, flexible sigmoidoscopy every five years, fecal occult blood testing every year combined with flexible sigmoidoscopy every five years, double-contrast barium enema every five to 10 years or colonoscopy every 10 years. Screening of persons with risk factors should begin at an earlier age, depending on the family history of colorectal cancer or polyps. These recommendations augment the colorectal cancer screening guidelines of the American Academy of Family physicians. Recent advances in genetic research have made it possible to identify persons at high risk for colorectal cancer because of an inherited predisposition to develop this malignancy. These patients require aggressive screening, usually by lower endoscopy performed at an early age. In some patients, genetic testing can guide screening and may be cost-effective.     

Has there been a change in practice of screening for prostate cancer with prostate-specific antigen in Ontario?

OBJECTIVE: To determine whether there has been a change in the rate of screening in Ontario in 2002 compared to 1995. METHODS: A questionnaire was mailed to 520 physicians, associated with PSA records selected randomly from the database of a large community laboratory. Physicians were asked to consult their records as to the reasons for PSA testing. RESULTS: There were 285 usable responses from 520 mailings (response rate 55%), mostly (91%) from family or general practice. Reasons for testing, expressed as proportions of responses, were as follows (this study, 1995 study and P value for the differences): screening for prostate cancer (74%, 63%; P = 0.059), diagnosis of urinary symptoms (30%, 40%; P = 0.027), follow-up of a medical procedure or drug therapy (14%, 32%; P = 0.001), confirmation of a previous PSA result (14%, 6%; P = 0.015) and other reasons (7%, 8%; P = 0.73). Of those records with screening as one reason for testing, 80% vs. 66% (P = 0.003) indicated it was the only reason; 86% vs. 73% (P = 0.003) indicated that it was part of a routine examination, and 54% vs. 64% (P = 0.052) indicated that the test was requested by the patient. CONCLUSION: These findings are consistent with increased screening for prostate cancer with PSA.     

An intervention study to increase colorectal cancer knowledge and screening among community elders

This study evaluates the effectiveness of a culturally relevant intervention, delivered over 12 months on knowledge of colorectal cancer and participation in fecal occult blood testing. An experimental, repeated measures design was used. Free fecal occult blood testing was offered to the participants. Fifteen senior centers were randomly selected and assigned to the Cultural and Self-Empowerment Group, the Modified Cultural Group, or the Traditional Group. Their mean age was 73.83 years, and their average educational level was 8.8 years. The majority was African American, female, and reported annual incomes < or = 10,000 dollars. Data were collected at baseline, at 6 months, and at 12 months. Participants in the Cultural and Self-Empowerment Group had a significantly greater increase in their knowledge of colorectal cancer over time. Group membership and knowledge of colorectal cancer were significant predictors of participation in colorectal cancer screening. Participants in the Cultural and Self-Empowerment Group and those with greater knowledge of colorectal cancer were more likely to participate in fecal occult blood testing at the end of the 12-month period. Similar strategies may be implemented in community settings and health care agencies to inform elders about colorectal cancer.     

Use of preventive services by Medicare fee-for-service beneficiaries: does spillover from managed care matter?

BACKGROUND: Health care delivery varies with the level of managed care activity (MCA) in an area, potentially affecting health care for those not participating in managed care programs. However, the extent to which MCA is associated with the use of cancer screening by fee-for-service beneficiaries (FFS) is unclear. OBJECTIVE: We sought to study colorectal cancer screening among Medicare FFS beneficiaries in relation to levels of Medicare MCA. RESEARCH DESIGN: This study linked 1999 Medicare denominator and Part B claims data with the 1998 Area Resource File. After categorizing MCA as low (<10%), moderate (10-29.99%), or high (> or =30%), we assessed the association between colorectal cancer screening among FFS beneficiaries and MCA, controlling for individual demographic variables and county-level attributes of socioeconomic status and physician resources. SUBJECTS: We included Medicare FFS beneficiaries 65 years of age or older with both Part A and Part B coverage for the entire calendar year from large counties in the study. MEASURES: We measured the likelihood of undergoing fecal occult blood testing (FOBT), flexible sigmoidoscopy (FLEX), or colonoscopy (COL). RESULTS: Compared with Medicare FFS beneficiaries residing in counties with low MCA, those in high MCA counties were significantly more likely to undergo FOBT (adjusted odds ratio [AOR] 1.10, 95% confidence interval [CI] 1.04-1.16), FLEX (AOR 1.11, 95% CI 1.04-1.18), or colonoscopy, after receiving FOBT/FLEX (AOR 1.07, 95% CI 1.02-1.13). CONCLUSIONS: From a public health perspective, an association between higher levels of MCA and colorectal cancer screening among those not enrolled in managed care may translate into modest increases in use of colorectal cancer screening and possibly earlier detection.     

The adult well male examination

The adult well male examination should incorporate evidence-based guidance toward the promotion of optimal health and well-being, including screening tests shown to improve health outcomes. Nearly one-third of men report not having a primary care physician. The medical history should include substance use; risk factors for sexually transmitted infections; diet and exercise habits; and symptoms of depression. Physical examination should include blood pressure and body mass index screening. Men with sustained blood pressures greater than 135/80 mm Hg should be screened for diabetes mellitus. Lipid screening is warranted in all men 35 years and older, and in men 20 to 34 years of age who have cardiovascular risk factors. Ultrasound screening for abdominal aortic aneurysm should occur between 65 and 75 years of age in men who have ever smoked. There is insufficient evidence to recommend screening men for osteoporosis or skin cancer. The U.S. Preventive Services Task Force has provisionally recommended against prostate-specific antigen-based screening for prostate cancer because the harms of testing and overtreatment outweigh potential benefits. Screening for colorectal cancer should begin at 50 years of age in men of average risk and continue until at least 75 years of age. Screening should be performed by high-sensitivity fecal occult blood testing every year, flexible sigmoidoscopy every five years combined with annual fecal occult blood testing, or colonoscopy every 10 years. The U.S. Preventive Services Task Force recommends against screening for testicular cancer and chronic obstructive pulmonary disease. Immunizations should be recommended according to guidelines from the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention.     

Cancer screening guidelines

Numerous medical organizations have developed cancer screening guidelines. Faced with the broad, and sometimes conflicting, range of recommendations for cancer screening, family physicians must determine the most reasonable and up-to-date method of screening. Major medical organizations have generally achieved consensus on screening guidelines for breast, cervical and colorectal cancer. For breast cancer screening in women ages 50 to 70, clinical breast examination and mammography are generally recommended every one or two years, depending on the medical organization. For cervical cancer screening, most organizations recommend a Papanicolaou test and pelvic examination at least every three years in patients between 20 and 65 years of age. Annual fecal occult blood testing along with flexible sigmoidoscopy at five-year to 10-year intervals is the standard recommendation for colorectal cancer screening in patients older than 50 years. Screening for prostate cancer remains a matter of debate. Some organizations recommend digital rectal examination and a serum prostate-specific antigen test for men older than 50 years, while others do not. In the absence of compelling evidence to indicate a high risk of endometrial cancer, lung cancer, oral cancer and ovarian cancer, almost no medical organizations have developed cancer screening guidelines for these types of cancer.     

An audit of all prostate-specific antigen tests requested by non-urologists in a 1-year period in a district general hospital

There has been much debate and controversy about prostate cancer screening and the use and abuse of the prostate‐specific antigen (PSA) test. Much of this debate is centred around primary care. It was noticed that increasing numbers of men admitted to secondary care, as patients of non‐urologists in a district general hospital, were having their PSA tested. A retrospective audit of all PSA tests requested during a 1‐year period was undertaken by a practicing clinical nurse specialist and consultant urologist. The reasons for the requests for the test were examined along with the implications of the results. The results showed that many PSA tests were requested without clinical indication or understanding of prostate cancer, without the patient’s knowledge or consent and without a clear interpretation of the results. Moreover, some patients who tested positive did not receive the appropriate investigations or treatment, thereby putting them at risk. This audit has shown a need for guidelines to be developed for PSA testing in the secondary care setting to complement those already in use in primary care.     

Exploring patient perceptions of PSA screening for prostate cancer: Risks, effectiveness, and importance

Objective

To study the beliefs of a group of Canadian men regarding the risks, effectiveness, and importance of routine prostate-specific antigen (PSA) testing when used as a screening tool for prostate cancer.

Design

A 1-page questionnaire designed to gauge patient beliefs about PSA screening.

Setting

Two primary care clinics in Kingston, Ont.

Participants

Seventy-two men aged 41 to 80.

Main outcome measures

Whether men believed that the PSA blood test was not risky when used as a screening test for prostate cancer, was effective at preventing death from prostate cancer, and was important for their health.

Results

Fifteen men reported having visited their physicians because of difficulty urinating in the past 2 years, or a personal history of prostate cancer, and were excluded; for these men, the use of the PSA blood test would not be for screening. Of the 57 men considered in the study, 54 (95%) believed that using the PSA blood test as a screening tool for prostate cancer was not risky, 39 (68%) believed that the PSA blood test was good or very good at preventing death from prostate cancer, and 45 (79%) believed that the routine use of the PSA blood test was important or very important for their health. Men in the suggested screening age group of 51 to 70 years (n = 32) had an equally positive impression of PSA screening.

Conclusion

Despite a limited body of evidence showing its effectiveness, Canadian men continue to have a favourable impression of PSA screening and remain largely unaware of potential adverse events associated with PSA testing.     

Behavioral interventions to increase adherence in colorectal cancer screening

This investigation was a randomized controlled trial to determine the impact of health education interventions on the return of mailed fecal occult blood (FOB) tests (FOBT adherence) in a colorectal cancer screening program. The study sample included 2,201 men and women aged 50 to 74 years who were members of an Independent Practice Association (IPA)-type health maintenance organization (HMO). Subjects were randomly assigned to a "usual care" Control Group (advance letter, screening kit, reminder letter), and Treatment Groups 1 (usual care + reminder call), 2 (usual care + self-held screening booklet + reminder call), or 3 (usual care + self-held screening booklet + instruction call + reminder call). Bivariate analysis revealed significant differences in adherence (P less than .001) across study groups: Control Group (27%), Group 1 (37%), Group 2 (37%), Group 3 (48%). In addition, a significant positive association between age and adherence (P less than .001) was found. Logistic regression analysis revealed an interaction between sex and treatment. Adherence among men in all treatment groups increased significantly (P less than .0001) in relation to Control Group males. Men in Group 3 also were more likely to adhere than those in Group 2 (P less than .01) or Group 1 (P less than .01). Among women, adherence was significantly higher in Group 3 than in Group 2 (P less than .03), Group 1 (P less than .025), or the Control Group (P = .0008). The primary reason cited for nonadherence was perceived inconvenience of the FOB testing procedure.     

PS2-33: Non-physician Providers, Cancer Screening and Health Behavior Counseling

Background Patients who receive a physician's recommendation for cancer screening and behavioral modification are most likely to comply with these recommendations. However, physicians face time constraints that make it nearly impossible to provide all recommended preventive services. Furthermore, the 2010 Affordable Care Act will expand health insurance coverage to 42 million Americans by 2014. This will increase demand for primary care. Non-physician providers may help meet this new demand for primary care and ensure compliance with preventive services recommendations. Methods Data from the 2005 National Health Interview Survey were analyzed using multivariate logistic regression to assess the association between provider type seen in past 12 months and compliance with U.S. Preventive Services Task Force cancer screening recommendations and receipt of behavior counseling among age-eligible adults (n=23,201). Models for each screening test were adjusted for age, level of education, and insurance status and stratified by gender. Results About 15% of NHIS participants (N=4,652) saw a non-physician provider (nurse practitioner, certified nurse midwife or physician assistant) and a primary care physician. In adjusted analyses, age-eligible women were more likely to be compliant with Pap screening (OR: 5.0; 95% CI: 4.2 - 5.9), mammography (OR: 6.6; 95% CI: 5.2 - 8.4) and colorectal screening recommendations (OR: 7.8; 95% CI: 5.3 - 11.4) if they saw a non-physician provider and primary care physician compared to not seeing any provider. Similarly, men were more likely to be compliant with colorectal screening recommendations (OR: 9.6; 95% CI: 6.9 - 13.5) if they saw a non-physician provider and primary care physician. Women and men were more likely to report a provider asking about smoking status if they saw a non-physician provider and primary care physician than those who saw other types of healthcare providers ((OR: 2.2; 95% CI: 2.0 - 2.4) and (OR: 3.0; 95% CI: 2.4 - 3.7), respectively). Conclusions Seeing a non-physician provider and a primary care physician is related to an increased likelihood of compliance with cancer screening recommendations and receipt of health behavior counseling. Opportunities exist for non-physician providers to increase cancer screening and receipt of behavioral counseling during this era of healthcare reform.     

Colorectal cancer screening

Colorectal cancer is an important problem in the United States, with over 130,000 new cases and 55,000 deaths each year. There is now strong evidence that screening for colorectal cancer with fecal occult blood testing can decrease mortality, and additional evidence that removing benign adenomas can decrease cancer incidence. Evidence-based screening guidelines depend on colorectal cancer risk. Individuals at higher risk because of a personal or family history deserve more intensive screening than asymptomatic individuals over age 50.     

Prostate Cancer in Primary Care

Prostate cancer is a common malignancy seen worldwide. The incidence has risen in recent decades, mainly fuelled by more widespread use of prostate-specific antigen (PSA) testing, although prostate cancer mortality rates have remained relatively static over that time period. A man’s risk of prostate cancer is affected by his age and family history of the disease. Men with prostate cancer generally present symptomatically in primary care settings, although some diagnoses are made in asymptomatic men undergoing opportunistic PSA screening. Symptoms traditionally thought to correlate with prostate cancer include lower urinary tract symptoms (LUTS), such as nocturia and poor urinary stream, erectile dysfunction and visible haematuria. However, there is significant crossover in symptoms between prostate cancer and benign conditions affecting the prostate such as benign prostatic hypertrophy (BPH) and prostatitis, making it very challenging to distinguish between them on the basis of symptoms. The evidence for the performance of PSA in asymptomatic and symptomatic men for the diagnosis of prostate cancer is equivocal. PSA is subject to false positive and false negative results, affecting its clinical utility as a standalone test. Clinicians need to counsel men about the risks and benefits of PSA testing to inform their decision-making. Digital rectal examination (DRE) by primary care clinicians has some evidence to show discrimination between benign and malignant conditions affecting the prostate. Patients referred to secondary care for diagnostic testing for prostate cancer will typically undergo a transrectal or transperineal biopsy, where a number of samples are taken and sent for histological examination. These biopsies are invasive procedures with side effects and a risk of infection and sepsis, and alternative tests such as multiparametric magnetic resonance imaging (mpMRI) are currently being trialled for their accuracy and safety in diagnosing clinically significant prostate cancer.     

Fecal-based DNA assays: a new, noninvasive approach to colorectal cancer screening

Stool-based DNA testing is a new, noninvasive method of colorectal cancer screening. Because it is easier to use and more sensitive than fecal occult blood testing, physicians may be more likely to recommend it, and patients may be more apt to comply. Although it is expensive, initial assessments show it to be cost-effective.     

Prostate cancer screening in primary care

BACKGROUND: Little is known about the actual frequency with which men have prostate screening in primary care settings, nor are the determinants of screening understood. METHODS: We examined the records of 50 consecutive primary care office visits by men aged 50 or older. Men were asked to complete a brief questionnaire outlining their previous use of prostate screening services and the factors that influenced screening. RESULTS: Screening in the previous year with digital rectal examination (DRE) and prostate specific antigen (PSA) was reported by 46% and 30% of respondents, respectively. Most respondents (86%) had heard of prostate screening and most (78%) believed it was effective. The only factor predictive of screening with DRE in multivariate analysis was a doctor's discussion of screening (odds ratio, 4.8). Two factors were predictive of PSA screening--knowing someone who had prostate cancer (odds ratio, 12.8) and advancing age (odds ratio [per year], 1.1). CONCLUSIONS: Many men are not having annual prostate screening. Men who were older, who reported knowing someone with prostate cancer, and whose doctors discussed screening, were more likely to have been screened in the past year.