Variation in Primary Care Physicians’ Colorectal Cancer Screening Recommendations by Patient Age and Comorbidity

BACKGROUND

Screening patterns among primary care physicians (PCPs) may be influenced by patient age and comorbidity. Colorectal cancer (CRC) screening has little benefit among patients with limited life expectancy.

OBJECTIVE

To characterize the extent to which PCPs modify their recommendations for CRC screening based upon patients’ increasing age and/or worsening comorbidity

DESIGN

Cross-sectional, nationally representative survey.

PARTICIPANTS

The study comprised primary care physicians (n = 1,266) including general internal medicine, family practice, and obstetrics-gynecology physicians.

MAIN MEASURES

Physician CRC screening recommendations among patients of varying age and comorbidity were measured based upon clinical vignettes. Independent variables in adjusted models included physician and practice characteristics.

KEY RESULTS

For an 80-year-old patient with unresectable non-small cell lung cancer (NSCLC), 25 % of PCPs recommended CRC screening. For an 80-year-old patient with ischemic cardiomyopathy (New York Heart Association, Class II), 71 % of PCPs recommended CRC screening. PCPs were more likely to recommend fecal occult blood testing than colonoscopy as the preferred screening modality for a healthy 80-year-old, compared to healthy 50- or 65-year-old patients (19 % vs. 5 % vs. 2 % p < 0.001). For an 80-year-old with unresectable NSCLC, PCPs who were an obstetrics-gynecology physician were more likely to recommend CRC screening, while those with a full electronic medical record were less likely to recommend screening.

CONCLUSIONS

PCPs consider comorbidity when screening older patients for CRC and may change the screening modality from colonoscopy to FOBT. However, a sizable proportion of PCPs would recommend screening for patients with advanced cancer who would not benefit. Understanding the mechanisms underlying these patterns will facilitate the design of future medical education and policy interventions to reduce unnecessary care.

Electronic supplementary material

The online version of this article (doi:10.1007/s11606-012-2093-6) contains supplementary material, which is available to authorized users.KEY WORDS: cancer screening, health services, colorectal cancer, primary care physicians     

Patient–Provider Discussions about Colorectal Cancer Screening: Who Initiates Elements of Informed Decision Making?

BACKGROUND

Colorectal cancer (CRC) screening rates remain low among low-income minority populations.

OBJECTIVE

To evaluate informed decision making (IDM) elements about CRC screening among low-income minority patients.

DESIGN

Observational data were collected as part of a patient-level randomized controlled trial to improve CRC screening rates. Medical visits (November 2007 to May 2010) were audio-taped and coded for IDM elements about CRC screening. Near the end of the study one provider refused recording of patients’ visits (33 of 270 patients). Among all patients in the trial, agreement to be audio taped was 43.5 % (103/237). Evaluable patient (n = 100) visits were assessed for CRC screening discussion occurrence, IDM elements, and who initiated discussion of each IDM element.

PARTICIPANTS

Patients were African American (72.2 %), female (63.7 %), with annual household incomes <$20,000 (60.7 %), without health insurance (57.0 %), and limited health literacy (53.7 %).

KEY RESULTS

Although CRC screening was mentioned during 48 (48 %) visits, no further discussion about screening occurred in 23 visits (19 times mentioned by the participant with no response from providers). During any visit, the maximum number of IDM elements was five; however, only two visits included five elements. The most common IDM element discussed in addition to the nature of the decision was the assessment of the patient’s understanding in 16 (33.3 %) of the visits that included a CRC discussion.

CONCLUSIONS

A patient activation intervention initiated CRC screening discussions with health care providers; however, limited IDM occurred about CRC screening during medical visits of minority and low-income patients.KEY WORDS: colorectal cancer, cancer screening, communication, decision making     

Comparing 3 Values Clarification Methods for Colorectal Cancer Screening Decision-Making: A Randomized Trial in the US and Australia

Purpose

To compare the effects of three methods of values clarification (VCM): balance sheet; rating and ranking; and a discrete choice experiment (DCE) on decision-making about colorectal cancer (CRC) screening among adults in the US and Australia.

Methods

Using online panels managed by a survey research organization in the US and Australia, we recruited adults ages 50–75 at average risk for CRC for an online survey. Those eligible were randomized to one of the three VCM tasks. CRC screening options were described in terms of five key attributes: reduction in risk of CRC incidence and mortality; nature of the screening test; screening frequency; complications from screening; and chance of requiring a colonoscopy (as initial or follow-up testing). Main outcomes included self-reported most important attribute and unlabeled screening test preference by VCM and by country, assessed after the VCM.

Results

A total of 920 participants were enrolled; 51 % were Australian; mean age was 59.0; 87.0 % were white; 34.2 % had a 4-year college degree; 42.8 % had household incomes less than $45,000 USD per year; 44.9 % were up to date with CRC screening. Most important attribute differed across VCM groups: the rating and ranking group was more likely to choose risk reduction as most important attribute (69.8 %) than the balance sheet group (54.7 %) or DCE (49.3 %), p < 0.0001; most important attribute did not vary by country (p = 0.236). The fecal occult blood test (FOBT)-like test was the most frequently preferred test overall (55.9 %). Unlabeled test choice did not differ meaningfully by VCM. Australians were more likely to prefer the FOBT (AU 66.2 % vs. US 45.1 %, OR 2.4, 95 % CI 1.8, 3.1). Few participants favored no screening (US: 9.2 %, AU: 6.2 %).

Conclusions

Screening test attribute importance varied by VCM, but not by country. FOBT was more commonly preferred by Australians than by Americans, but test preferences were heterogeneous in both countries.

Electronic supplementary material

The online version of this article (doi:10.1007/s11606-013-2701-0) contains supplementary material, which is available to authorized users.KEY WORDS: values clarification, colorectal cancer screening, patient decision support     

Risk of progression of advanced adenomas to colorectal cancer by age and sex: estimates based on 840,149 screening colonoscopies

Objectives

To derive age and sex specific estimates of transition rates from advanced adenomas to colorectal cancer by combining data of a nationwide screening colonoscopy registry and national data on colorectal cancer (CRC) incidence.

Design

Registry based study.

Setting

National screening colonoscopy programme in Germany.

Patients

Participants of screening colonoscopy in 2003 and 2004 (n = 840 149).

Main outcome measures

Advanced adenoma prevalence, colorectal cancer incidence, annual and 10 year cumulative risk of developing CRC among carriers of advanced adenomas according to sex and age (range 55–80+ years)

Results

The age gradient is much stronger for CRC incidence than for advanced adenoma prevalence. As a result, projected annual transition rates from advanced adenomas to CRC strongly increase with age (from 2.6% in age group 55–59 years to 5.6% in age group ⩾80 years among women, and from 2.6% in age group 55–59 years to 5.1% in age group ⩾80 years among men). Projections of 10 year cumulative risk increase from 25.4% at age 55 years to 42.9% at age 80 years in women, and from 25.2% at age 55 years to 39.7% at age 80 years in men.

Conclusions

Advanced adenoma transition rates are similar in both sexes, but there is a strong age gradient for both sexes. Our estimates of transition rates in older age groups are in line with previous estimates derived from small case series in the pre‐colonoscopy era independent of age. However, our projections for younger age groups are considerably lower. These findings may have important implications for the design of CRC screening programmes.Most colorectal cancers (CRCs) develop from adenomas, among which “advanced” adenomas are considered to be the clinically relevant precursors of CRC. The natural history of colorectal adenomas is a decisive factor for the design of CRC screening measures and their cost effectiveness. Since advanced adenomas need to be removed once they are detected, any direct observation of their natural history would be unethical. Thus, available estimates for the progression of adenomas mostly stem from radiological surveillance data or from autopsy series collected prior to the colonoscopy era.^{1,2,3,4,5,6,7,8,9} However, these data are rather vague as they were derived from small and potentially selective samples. For example, a major source for the estimation of adenoma transition rates has been a retrospective review of Mayo Clinic records from 226 patients with colonic polyps ⩾10 mm in diameter in whom periodic radiographical examination of the colon was performed, and in whom 21 invasive carcinomas were identified during a mean follow up of 9 years.⁹ Despite the undoubted usefulness of available data sources from the pre‐colonoscopy era, sample size limitations did not allow reliable estimates of adenoma transition rates according to key factors, such as age and sex. Accordingly, a common estimate of these transition rates for all ages and both sexes has generally been assumed in previous studies on effectiveness and cost effectiveness of CRC screening.^{10,11,12,13,14,15,16,17} Given that sensitivity analyses in these studies showed that the advanced adenoma–carcinoma transition rate represents a very influential parameter,^10,11,13,18 its variation by age and sex might have a large impact on relative effectiveness and cost effectiveness of various screening schemes.The aim of this paper was to estimate risk for developing CRC according to age and sex among carriers of advanced adenomas by combining data from a large national colonoscopy screening database and national data on CRC incidence in Germany.     

Overuse of Colonoscopy for Colorectal Cancer Screening and Surveillance

BACKGROUND

Ongoing efforts to increase colorectal cancer (CRC) screening rates have raised concerns that these exams may be overused, thereby subjecting patients to unnecessary risks and wasting healthcare resources.

OBJECTIVE

Our aim was to measure overuse of screening and surveillance colonoscopies among average-risk adults, and to identify correlates of overuse.

DESIGN, SETTING, AND PARTICIPANTS

Our approach was a retrospective cohort study using electronic health record data for patients 50–65 years old with no personal history of CRC or colorectal adenomas with an incident CRC screening colonoscopy from 2001 to 2010 within a multispecialty physician group practice.

MAIN OUTCOME MEASURES

We measured time to next screening or surveillance colonoscopy and predictors of overuse (exam performed more than one year earlier than guideline recommended intervals) of colonoscopies.

KEY RESULTS

We identified 1,429 adults who had an incident colonoscopy between 2001 and 2010, and they underwent an additional 871 screening or surveillance colonoscopies during a median follow-up of 6 years. Most follow-up screening colonoscopies (88 %) and many surveillance colonoscopies (49 %) repeated during the study represented overuse. Time to next colonoscopy after incident screening varied by exam findings (no polyp: median 6.9 years, interquartile range [IQR]: 5.1–10.0; hyperplastic polyp: 5.7 years, IQR: 4.9–9.7; low-risk adenoma: 5.1 years, IQR: 3.3–6.3; high-risk adenoma: 2.9 years, IQR: 2.0–3.4, p < 0.001). In logistic regression models of colonoscopy overuse, an endoscopist recommendation for early follow-up was strongly associated with overuse of screening colonoscopy (OR 6.27, 95 % CI: 3.15–12.50) and surveillance colonoscopy (OR 13.47, 95 % CI 6.61-27.46). In a multilevel logistic regression model, variation in the overuse of screening colonoscopy was significantly associated with the endoscopist performing the previous exam.

CONCLUSIONS

Overuse of screening and surveillance exams are common and should be monitored by healthcare systems. Variations in endoscopist recommendations represent targets for interventions to reduce overuse.KEY WORDS: colorectal cancer screening, colonoscopy, overuse, efficiency     

Reactions to a targeted intervention to increase fecal occult blood testing among average-risk adults waiting for screening colonoscopy

BACKGROUND:

Increasing demand combined with limited capacity has resulted in long wait times for average-risk adults referred for screening colonoscopy for colorectal cancer. Management of patients on these growing wait lists is an emerging clinical issue.

OBJECTIVE:

To inform the content and design of a mailed targeted invitation for patients to undergo annual fecal occult blood testing (FOBT) while awaiting colonoscopy.

METHODS:

Focus groups (FGs) with average-risk patients on a wait list for screening colonoscopy at a high-throughput academic outpatient colonoscopy facility were conducted. During each FG session, feedback regarding a range of materials under consideration for the planned intervention was elicited using a semistructured facilitator guide. The FG sessions were recorded and transcribed verbatim, and analyzed using the constant comparative method to identify key themes.

RESULTS:

Findings from the three FGs (n=28) suggested that average-risk patients on a wait list for screening colonoscopy would be receptive to a targeted intervention recommending they undergo FOBT while waiting. Participants indicated that the invitation to undergo FOBT was an important acknowledgement that they were on an actively managed list, and that a mechanism to ensure that they were correctly triaged while waiting was in place. Several specific suggestions to improve the design of the targeted intervention were obtained.

CONCLUSIONS:

Results of the present study provide useful information for developing effective strategies to manage average-risk individuals facing long wait times for screening colonoscopy.     

Short term outcomes of the first round of a pilot colorectal cancer screening programme with guaiac based faecal occult blood test

Objective

To assess both feasibility and short term outcomes of a population based colorectal cancer screening programme using a biennial guaiac based faecal occult blood test (gFOBT).

Method

All participants were invited by mail to take part in a screening programme using a non‐rehydrated gFOBT. The gFOBTs were first provided by general practitioners (GPs) and then directly mailed to individuals who failed to comply after two invitations. The setting was a French administrative district: Haut‐Rhin (710 000 inhabitants). 182 981 residents aged 50–74 years were invited to participate.

Results

19 274 people (10.5%) were excluded from gFOBT screening and 90 706 completed a gFOBT, so that the participation rate was 55.4% of those eligible. 76.5% of the completed gFOBTs were provided by GPs and 15.5% by direct mailing. The gFOBT positivity rate was 3.4%. The positive predictive value was 42.7% for neoplasia (women 30.8%, men 52.5%), 23.6% for advanced adenoma, and 7.6% for cancer. The number of normal colonoscopic procedures (without neoplasia) needed to be performed for each colonoscopy detecting an advanced neoplasia was 1.8, lower in men (1.2) than in women (3.4), and decreasing with age. Detection rates for neoplasia and cancer were 12.8 and 2.3 per 1000 people screened. 206 adenocarcinomas were detected: 47.6% were stage I and 23.8% stage II. The direct cost was estimated at €29.3 per screened person and €13 466 per cancer detected.

Conclusions

Participation and diagnostic yield of controlled trials of gFOBT screening are reproducible in the real world at an acceptable cost through an organised population based programme involving GPs.     

Parasitic disease screening among HIV patients from endemic countries in a Toronto clinic

BACKGROUND:

Many North American-based HIV patients originate from parasitic disease-endemic regions. Strongyloidiasis, schistosomiasis and filariasis are important due to their wide distribution and potential for severe morbidity.

OBJECTIVES:

To determine the prevalence, as determined by serological screening, of strongyloidiasis, schistosomiasis and filariasis among patients in an HIV-focused, primary care practice in Toronto, Ontario. A secondary objective was to determine factors associated with positive serological screens.

METHODS:

A retrospective review of electronic patient records was conducted. Results of serological screens for parasites and relevant laboratory data were collected.

RESULTS:

Ninety-seven patients were identified. The patients’ mean CD4⁺ count was 0.45×10⁹/L, median viral load was undetectable and 68% were on highly active antiretroviral therapy (HAART). Most originated from Africa (37%) and South America (35%). Of the 97 patients, 10.4% and 8.3% had positive or equivocal screening results for strongyloidiasis, respectively, 7.4% and 4.2% had positive or equivocal screening results for schistosomiasis and 5.5% and 6.8% had positive or equivocal screens for filariasis. Persons with positive parasitic serologies were more often female (28% versus 9%, P=0.03), younger in age (36 versus 43 years of age, P<0.01), had been in Canada for a shorter duration (5 versus 12 years, P<0.0001) and had a higher viral load (10,990 copies/mL versus <50 copies/mL, P <0.001). All patients were asymptomatic. Eosinophilia was not associated with positive screening results.

CONCLUSIONS:

Using symptoms and eosinophilia to identify parasitic infection was not reliable. Screening for strongyloidiasis and schistosomiasis among patients with HIV from parasite-endemic countries is simple and benign, and may prevent future complications. The clinical benefits of screening for filariasis require further elucidation, but this practice appears to be the least warranted.     

Comparative Effectiveness of Multifaceted Outreach to Initiate Colorectal Cancer Screening in Community Health Centers: A Randomized Controlled Trial

INTRODUCTION

Colorectal cancer (CRC) screening rates are low among vulnerable populations. Fecal immunochemical tests (FITs) are one screening modality with few barriers. Studies have shown that outreach can improve CRC screening, but little is known about its effectiveness among individuals with no CRC screening history. We sought to determine whether outreach increases FIT uptake among patients with no CRC screening history compared to usual care.

METHODS

This study was a patient-level randomized controlled trial, including 420 patients who had never completed CRC screening and were eligible for FIT; 66 % were female, 62.1 % were Latino, and 70.7 % were uninsured. The main outcome measure was FIT completion within 6 months of the randomization date. We assessed FIT completion at different time points corresponding to receipt of outreach components. All analyses were re-run with 12-month data.

RESULTS

Patients who received outreach were more likely to complete FIT than those in usual care (36.7 % vs. 14.8 %; p < 0.001). FIT completion was more common among patients with increased clinic visits. The difference in FIT completion between the outreach and usual care groups decreased over time.

DISCUSSION

The intervention improved FIT uptake among patients with no CRC screening history. However, the intervention was less effective than in a previous trial targeting patients due for repeat screening. Additional research is needed to determine the best methods for improving CRC screening among this hard-to-reach group.KEY WORDS: health disparities, cancer prevention, care delivery system     

Determinants of inappropriate circadian blood pressure variability in children with essential hypertension

BACKGROUND:

Inappropriate daily profile of blood pressure deteriorates the clinical outcome of hypertension and increases distant cardiovascular risk. The problem is important, especially in children and adolescents in whom early intervention helps to prevent complications of hypertension such as left ventricular hypertrophy and hypertensive retinopathy.

OBJECTIVES:

To assess circadian blood pressure profile and basic determinants of inappropriate daily blood pressure variability in hypertensive children.

METHODS:

The project was conducted retrospectively in 106 children six to 18 years of age (mean [± SD] 14.9±2.5 years) with essential hypertension and no use of antihypertensive drugs. The study group included 43 children with inappropriate daily blood pressure variability (‘nondippers’) and 63 controls with appropriate daily blood pressure variability (‘dippers’).

RESULTS:

Nondippers, compared with dippers, had higher systolic and diastolic blood pressure at night (systolic, 123.9±10.3 mmHg versus 113.9±8.2 mmHg; diastolic, 65.1±7.6 mmHg versus 59.5±6.5 mmHg; P<0.0001), and higher blood pressure load at night (systolic, 61.9% versus 27.6%; diastolic, 20.0% versus 9.6%; P<0.0001). Male sex increased the risk for nondipping by 2.5 times (logistic OR=2.45; 95% CI 0.87 to 6.87). However, the increase was statistically nonsignificant (P=0.08). No differences were observed between dippers and nondippers in terms of anthropometric profile, family history of hypertension, morphological and biochemical blood parameters, and birth weight.

CONCLUSIONS:

Among hypertensive children, nondippers have a more severe degree of hypertension. Male sex increases the risk of nondipping. To assess determinants of nondipping more precisely, further clinical investigations are needed.     

Different screening definitions have little impact on polypectomy rate estimates

BACKGROUND:

Polypectomy rate is a surrogate quality indicator for screening colonoscopy. Various methods for identifying screening colonoscopies have been used and it is unclear how different definitions affect the estimated polypectomy rate.

OBJECTIVE:

To estimate polypectomy rates and how they vary according to the definition of a screening colonoscopy, using patient- and endoscopist-reported indications.

METHODS:

A cross-sectional analysis of endoscopists and their patients 50 to 75 years of age who underwent colonoscopy was conducted. Based on questionnaire responses, four patient indications were derived: perceived screening; perceived nonscreening; medical history indicating nonscreening; and combination of the three indications. Endoscopist indication was derived from a questionnaire completed immediately after colonoscopy. Polypectomy status was obtained from provincial physician billing records. Polypectomy rates were computed, while accounting for physician and hospital level clustering, using all four patient indications, endoscopist indication, and the agreement between patient and endoscopist indications. The effect of indications on polypectomy rate was estimated adjusting for age, sex and family history of colorectal cancer.

RESULTS:

A total of 2134 patients and 45 endoscopists were included. The proportion of colonoscopies classified as screening according to the nine indications ranged from 32.2% to 70.9%. Polypectomy rates ranged between 22.6% and 26.2% for screening colonoscopy, and between 27.1% and 30.8% for nonscreening colonoscopy. Adjusted ORs for indication ranged between 0.74 and 0.94.

DISCUSSION:

Although the proportion of colonoscopies identified as screening varied considerably among the indications, the estimated polypectomy rates were similar.

CONCLUSION:

The findings suggest that the way screening is defined does not greatly affect the estimates of polypectomy rate.     

The Effectiveness of a Physician-Only and Physician–Patient Intervention on Colorectal Cancer Screening Discussions Between Providers and African American and Latino Patients

BACKGROUND

Physician recommendation of colorectal cancer (CRC) screening is a critical facilitator of screening completion. Providing patients a choice of screening options may increase CRC screening completion, particularly among racial and ethnic minorities.

OBJECTIVE

Our purpose was to assess the effectiveness of physician-only and physician–patient interventions on increasing rates of CRC screening discussions as compared to usual care.

DESIGN

This study was quasi-experimental. Clinics were allocated to intervention or usual care; patients in intervention clinics were randomized to receipt of patient intervention.

PARTICIPANTS

Patients aged 50 to 75 years, due for CRC screening, receiving care at either a federally qualified health care center or an academic health center participated in the study.

INTERVENTION

Intervention physicians received continuous quality improvement and communication skills training. Intervention patients watched an educational video immediately before their appointment.

MAIN MEASURES

Rates of patient-reported 1) CRC screening discussions, and 2) discussions of more than one screening test.

KEY RESULTS

The physician–patient intervention (n = 167) resulted in higher rates of CRC screening discussions compared to both physician-only intervention (n = 183; 61.1 % vs.50.3 %, p = 0.008) and usual care (n = 153; 61.1 % vs. 34.0 % p = 0.03). More discussions of specific CRC screening tests and discussions of more than one test occurred in the intervention arms than in usual care (44.6 % vs. 22.9 %,p = 0.03) and (5.1 % vs. 2.0 %, p = 0.036), respectively, but discussion of more than one test was uncommon. Across all arms, 143 patients (28.4 %) reported discussion of colonoscopy only; 21 (4.2 %) reported discussion of both colonoscopy and stool tests.

CONCLUSIONS

Compared to usual care and a physician-only intervention, a physician–patient intervention increased rates of CRC screening discussions, yet discussions overwhelmingly focused solely on colonoscopy. In underserved patient populations where access to colonoscopy may be limited, interventions encouraging discussions of both stool tests and colonoscopy may be needed.KEY WORDS: colorectal cancer screening, health literacy, randomized trial, physician communication of preventive care     

Diabetes and Prior Coronary Heart Disease are Not Necessarily Risk Equivalent for Future Coronary Heart Disease Events

Background

For more than a decade, the presence of diabetes has been considered a coronary heart disease (CHD) “risk equivalent”.

Objective

The objective of this study was to revisit the concept of risk equivalence by comparing the risk of subsequent CHD events among individuals with or without history of diabetes or CHD in a large contemporary real-world cohort over a period of 10 years (2002 to 2011).

Design

Population-based prospective cohort analysis.

Participants

We studied a cohort of 1,586,061 adult members (ages 30–90 years) of Kaiser Permanente Northern California, an integrated health care delivery system.

Main Measurements

We calculated hazard ratios (HRs) from Cox proportional hazard models for CHD among four fixed cohorts, defined by prevalent (baseline) risk group: no history of diabetes or CHD (None), prior CHD alone (CHD), diabetes alone (DM), and diabetes and prior CHD (DM + CHD).

Key Results

We observed 80,012 new CHD events over the follow-up period (~10,980,800 person-years). After multivariable adjustment, the HRs (reference: None) for new CHD events were as follows: CHD alone, 2.8 (95 % CI, 2.7–2.85); DM alone 1.7 (95 % CI, 1.66–1.74); DM + CHD, 3.9 (95 % CI, 3.8–4.0). Individuals with diabetes alone had significantly lower risk of CHD across all age and sex strata compared to those with CHD alone (12.2 versus 22.5 per 1000 person-years). The risk of future CHD for patients with a history of either DM or CHD was similar only among those with diabetes of long duration (≥10 years).

Conclusions

Not all individuals with diabetes should be unconditionally assumed to be a risk equivalent of those with prior CHD.KEY WORDS: coronary heart disease, diabetes, epidemiology     

The impact of hepatitis B knowledge and stigma on screening in Canadian Chinese persons

BACKGROUND

Chronic hepatitis B (CHB) infection is endemic in East Asia, and those who emigrate to North America have higher rates of CHB infection when compared with the general population. To date, Chinese persons residing in Canada have not been mandated to be screened for CHB infection.

OBJECTIVE:

To understand factors that influence hepatitis B screening behaviour among the Chinese community in Toronto, Ontario, and to determine whether stigma acts as a barrier to screening.

METHODS:

Self-identified Chinese individuals at a family physician’s office and at English as a second language (ESL) classes in Toronto completed a questionnaire with demographic questions, a hepatitis B virus (HBV) stigma scale and an HBV knowledge scale. Pearson product moment correlation and multiple regression techniques were used to analyze the data.

RESULTS:

The study group included 343 individuals. Their mean (± SD) age was 48.76±17.49 years and the majority were born in China (n=229 [68%]). The mean score on the HBV knowledge scale was 10.13±1.76 (range 0 to 15), with higher scores indicating greater HBV knowledge. The mean score on the stigma scale was 54.60±14.18 (range 20 to 100), with higher scores indicating more stigma. Being an immigrant, having a family physician and having greater knowledge of HBV were associated with increased rates of screening for this infection. In contrast, greater levels of HBV stigma were associated with decreased likelihood of screening for HBV infection.

CONCLUSIONS:

HBV stigma is associated with reduced rates of screening for this infection.     

Rates and Correlates of Potentially Inappropriate Colorectal Cancer Screening in the Veterans Health Administration

BACKGROUND

Inappropriate use of colorectal cancer (CRC) screening procedures can inflate healthcare costs and increase medical risk. Little is known about the prevalence or causes of inappropriate CRC screening.

OBJECTIVE

Our aim was to estimate the prevalence of potentially inappropriate CRC screening, and its association with patient and facility characteristics in the Veterans Health Administration (VHA) .

DESIGN AND PARTICIPANTS

We conducted a cross-sectional study of all VHA patients aged 50 years and older who completed a fecal occult blood test (FOBT) or a screening colonoscopy between 1 October 2009 and 31 December 2011 (n = 1,083,965).

MAIN MEASURES

Measures included: proportion of patients whose test was classified as potentially inappropriate; associations between potentially inappropriate screening and patient demographic and health characteristics, facility complexity, CRC screening rates, dependence on FOBT, and CRC clinical reminder attributes.

KEY RESULTS

Of 901,292 FOBT cases, 26.1 % were potentially inappropriate (13.9 % not due, 7.8 % limited life expectancy, 11.0 % receiving FOBT when colonoscopy was indicated). Of 134,335 screening colonoscopies, 14.2 % were potentially inappropriate (10.4 % not due, 4.4 % limited life expectancy). Each additional 10 years of patient age was associated with an increased likelihood of undergoing potentially inappropriate screening (ORs = 1.60 to 1.83 depending on screening mode). Compared to facilities scoring in the bottom third on a measure of reliance on FOBT (versus screening colonoscopy), facilities scoring in the top third were less likely to conduct potentially inappropriate FOBTs (OR = 0.,78) but more likely to conduct potentially inappropriate colonoscopies (OR = 2.20). Potentially inappropriate colonoscopies were less likely to be conducted at facilities where primary care providers were assigned partial responsibility (OR = 0.74) or full responsibility (OR = 0.73) for completing the CRC clinical reminder.

CONCLUSIONS

A substantial number of VHA CRC screening tests are potentially inappropriate. Establishing processes that enforce appropriate screening intervals, triage patients with limited life expectancies, and discourage the use of FOBTs when a colonoscopy is indicated may reduce inappropriate testing.KEY WORDS: colorectal cancer, screening, utilization, practice variation, VeteransIn 2014, an estimated 136,830 Americans will be diagnosed with colorectal cancer (CRC),¹ and an estimated 50,310 will die of the disease.¹ Appropriately applied, routine screening can reduce both CRC incidence and mortality.² Thus, many health organizations, including the Veterans Health Administration (VHA), have invested heavily in programs to increase CRC screening. Clinical reminder systems are now commonly used to alert providers at the point of care when patients are due for screening. CRC screening performance measures are now included in most quality measurement systems. In the VHA, CRC screening rates are used as one measure of the quality of care provided by physicians, clinics and facilities, and can affect clinician and administrator compensation plans. As a result, the VHA CRC screening rate of 80 %³ is well above US general population rates.⁴One potential unintended consequence of the emphasis on screening promotion is the inappropriate use of screening tests. There are at least three reasons a CRC screening test could be clinically inappropriate. First, the patient may not be due for screening. The US Preventive Services Task Force recommends screening with fecal occult blood tests (FOBTs) annually, with colonoscopy every 10 years, or with flexible sigmoidoscopy every 5 years.⁵ Second, the patient may be unlikely to live long enough to realize a screening benefit. Decision analyses and a meta-analysis of randomized controlled trial (RCT) data suggest that average-risk individuals with a life expectancy of less than 10 years are unlikely to benefit from CRC screening.^6,7 Third, the patient may receive the wrong test. Generally, patients with CRC-related symptoms or with a personal or family history of CRC should undergo colonoscopy (not FOBT or other tests).⁸ Screening patients who are not yet due or who are of limited life expectancy can strain gastroenterology and laboratory resources and expose patients to unnecessary inconvenience, stress, and medical risk. Serious complications are estimated to occur in 25 per 10,000 colonoscopy procedures,⁹ and deaths attributable to colonoscopy occur in three per 10,000 procedures.¹⁰ These forms of inappropriate screening can result in harm even when FOBTs are used because, if the FOBT is positive, the patient may undergo a diagnostic colonoscopy. Utilizing FOBTs when a colonoscopy is indicated may delay or decrease the likelihood of undergoing a needed colonoscopy, potentially decreasing the benefits of screening.Previous studies of inappropriate CRC screening^11–14 assessed only one facility, one screening mode, or one category of inappropriate screening. The current study quantifies the extent of potentially inappropriate screening for both FOBT and colonoscopy in the entire VHA system (130 medical facilities), using a measure that distinguishes between three types of inappropriate screening (not due, limited life expectancy, and wrong test), and examines the association between this measure and patient and facility attributes.     

Screening Colonoscopy in the US: Attitudes and Practices of Primary Care Physicians

Background

Rising colorectal cancer (CRC) screening rates in the last decade are attributable almost entirely to increased colonoscopy use. Little is known about factors driving the increase, but primary care physicians (PCPs) play a central role in CRC screening delivery.

Objective

Explore PCP attitudes toward screening colonoscopy and their associations with CRC screening practice patterns.

Design

Cross-sectional analysis of data from a nationally representative survey conducted in 2006–2007.

Participants

1,266 family physicians, general practitioners, general internists, and obstetrician-gynecologists.

Main Measures

Physician-reported changes in the volume of screening tests ordered, performed or supervised in the past 3 years, attitudes toward colonoscopy, the influence of evidence and perceived norms on their recommendations, challenges to screening, and practice characteristics.

Results

The cooperation rate (excludes physicians without valid contact information) was 75%; 28% reported their volume of FOBT ordering had increased substantially or somewhat, and the majority (53%) reported their sigmoidoscopy volume decreased either substantially or somewhat. A majority (73%) reported that colonoscopy volume increased somewhat or substantially. The majority (86%) strongly agreed that colonoscopy was the best of the available CRC screening tests; 69% thought it was readily available for their patients; 59% strongly or somewhat agreed that they might be sued if they did not offer colonoscopy to their patients. All three attitudes were significantly related to substantial increases in colonoscopy ordering.

Conclusions

PCPs report greatly increased colonoscopy recommendation relative to other screening tests, and highly favorable attitudes about colonoscopy. Greater emphasis is needed on informed decision-making with patients about preferences for test options.KEY WORDS: colorectal cancer screening, primary care physicians, colonoscopy screening practices     

Prevalence of high Epworth Sleepiness Scale scores in a rural population

BACKGROUND:

Increased daytime sleepiness is an important symptom of obstructive sleep apnea (OSA). OSA is frequently underdiagnosed, and the Epworth Sleepiness Scale (ESS) can be a useful tool in alerting physicians to a potential problem involving OSA.

OBJECTIVE:

To measure the prevalence and determinants of daytime sleepiness measured using the ESS in a rural community population.

METHODS:

A community survey was conducted to examine the risk factors associated with ESS in a rural population in 154 households comprising 283 adults. Questionnaire information was obtained regarding physical factors, social factors, general medical history, family medical history, ESS score, and self-reported height and weight. Multivariable binary logistic regression analysis based on the generalized estimating equations approach to account for clustering within households was used to predict the relationship between a binary ESS score outcome (normal or abnormal) and a set of explanatory variables.

RESULTS:

The population included 140 men (49.5%) and 143 women (50.5%) with an age range of 18 to 97 years (mean [± SD] 52.0±14.9 years). The data showed that 79.2% of the study participants had an ESS score in the normal range (0 to 10) and 20.8% had an ESS score >10, which is considered to be abnormal or high sleepiness. Multivariable regression analysis revealed that obesity was significantly associated with an abnormal or high sleepiness score on the ESS (OR 3.40 [95% CI 1.31 to 8.80).

CONCLUSION:

High levels of sleepiness in this population were common. Obesity was an important risk factor for high ESS score.     

Gastrostomy tube insertion in children: the Edmonton experience

BACKGROUND:

Although gastrostomy tube insertion – whether endoscopic or open – is generally safe, procedure-related complications have been reported.

OBJECTIVE:

To compare gastrostomy tube insertion-related complications between percutaneous endoscopic gastrostomy and open gastrostomy at a single pediatric centre.

METHODS:

The charts of children (younger than 17 years of age at the time of tube insertion) who underwent endoscopic or open gastrostomy tube insertion from January 2005 to December 2007 at the Stollery Children’s Hospital (Edmonton, Alberta) were examined.

RESULTS:

A total of 298 children underwent gastrostomy tube insertion over a period of three years. After excluding patients with incomplete charts, 160 children (91 boys, mean [± SD] age 3.18±4.73 years) were included. Eighty-five children (mean age 4.50±5.40 years) had their gastrostomy tube inserted endoscopically, while the remaining 75 (mean age 1.68±3.27 years; P<0.001) underwent an open procedure. The overall rate of major complications was 10.2% for the endoscopic technique and 8.6% for the open technique (P=0.1). Major infections were higher in the endoscopic technique group, while persistent gastrocutaneous fistulas after tube removal were more common in the open technique group.

CONCLUSION:

Although the rate of major complications was similar between the endoscopic and open tube insertion groups, major infections were more common among children who underwent endoscopic gastrostomy. The decision for gastrostomy tube insertion was primarily based on clinical background.