Adam A. Powell

Validation of Self-Reported Colorectal Cancer Screening Behavior from a Mixed-Mode Survey of Veterans

Objective: The aim of the study was to validate self-reported colorectal cancer (CRC) screening using the National Cancer Institute Colorectal Cancer Screening questionnaire. Materials and Methods: 890 patients, ages 50 to 75 years, from the Minneapolis Veterans Affairs (VA) Medical Center were surveyed by mail. Phone administration was attempted with mail nonresponders. VA and non-VA records were combined for the reference standard. Sensitivity, specificity, concordance, and report-to-records ratio (R2R) were estimated for overall and test-specific CRC adherence among respondents providing complete medical records. Secondary analyses examined variation in estimates by patient characteristics, treatment of missing and uncertain responses, and whether a strict or liberal time interval was used for assessing concordance. Results: Complete medical records were available for 345 of the 686 survey responders. For overall adherence, sensitivity was 0.98, specificity was 0.59, concordance was 0.88, and R2R was 1.14. Sensitivity was 0.82 for fecal occult blood test (FOBT), 0.75 for sigmoidoscopy, 0.97 for colonoscopy, and 0.63 for double-contrast barium enema (DCBE). Specificity was 0.89 for FOBT, 0.76 for sigmoidoscopy, 0.72 for colonoscopy, and 0.85 for DCBE. Concordance was >0.80 for all tests other than sigmoidoscopy (0.76). R2R was 1.31 for FOBT, 1.33 for sigmoidoscopy, 1.42 for colonoscopy, and 6.13 for DCBE. The R2R was lower for a combined sigmoidoscopy and colonoscopy measure. Overreporting was more pronounced for older, less-educated individuals with no family history of CRC. Sensitivity and R2R improved using a liberal interval and treating uncertain responses as nonadherent (versus missing), but differences were not statistically significant. Conclusions: Self-reported CRC screening validity is generally acceptable and robust across definitional decisions, but varies by screening test and patient characteristics. (Cancer Epidemiol Biomarkers Prev 2008;17(4):768–76)

Unintended Consequences of Implementing a National Performance Measurement System into Local Practice

ABSTRACTBACKGROUNDAlthough benefits of performance measurement (PM) systems have been well documented, there is little research on negative unintended consequences of performance measurement systems in primary care. To optimize PM systems, a better understanding is needed of the types of negative unintended consequences that occur and of their causal antecedents.OBJECTIVES(1) Identify unintended negative consequences of PM systems for patients. (2) Develop a conceptual framework of hypothesized relationships between PM systems, facility-level variables (local implementation strategies, primary care staff attitudes and behaviors), and unintended negative effects on patients.DESIGN, PARTICIPANTS, APPROACHQualitative study design using dissimilar cases sampling. A series of 59 in-person individual semi-structured interviews at four Veterans Health Administration (VHA) facilities was conducted between February and July 2009. Participants included members of primary care staff and facility leaders. Sites were selected to assure variability in the number of veterans served and facility scores on national VHA performance measures. Interviews were recorded, transcribed and content coded to identify thematic categories and relationships.RESULTSParticipants noted both positive effects and negative unintended consequences of PM. We report three negative unintended consequences for patients. Performance measurement can (1) lead to inappropriate clinical care, (2) decrease provider focus on patient concerns and patient service, and (3) compromise patient education and autonomy. We also illustrate examples of negative consequences on primary care team dynamics. In many instances these problems originate from local implementation strategies developed in response to national PM definitions and policies.CONCLUSIONSFacility-level strategies undertaken to implement national PM systems may result in inappropriate clinical care, can distract providers from patient concerns, and may have a negative effect on patient education and autonomy. Further research is needed to ascertain how features of centralized PM systems influence whether measures are translated locally by facilities into more or less patient-centered policies and processes.

Developing and Sustaining Quality Improvement Partnerships in the VA: The Colorectal Cancer Care Collaborative

ObjectiveThe Veterans Affairs (VA) Quality Enhancement Research Initiative (QUERI) seeks to develop partnerships between VA health services researchers and clinical managers, with the goal of designing and evaluating interventions to improve the quality of VA health care.MethodsIn the present report we describe one such initiative aimed at enhancing the continuum of colorectal cancer (CRC) care, including diagnosis, treatment and surveillance–the Colorectal Cancer Care Collaborative (C4).ResultsWe describe the process and thinking that led to two parallel quality improvement “collaboratives” that addressed (1) CRC screening and diagnostic follow-up and (2) the guideline concordance and timeliness of CRC treatment. Additionally, we discuss ongoing effort to spread lessons learned during the first stages of the project, which initially occurred at only a subset of VA facilities, throughout the VA health care system. The description of this initiative is organized around key questions that must be answered when developing, sustaining and spreading multi-component quality improvement interventions.ConclusionWe conclude with a discussion of lessons learned that we believe would apply to similar initiatives elsewhere, even if they address different clinical issues in health care settings with different organizational structures.

Race and the validity of self-reported cancer screening behaviors: Development of a conceptual model

BACKGROUND Many estimates of cancer screening are based on self-reported screening behavior. There is growing concern that self-reported screening measures may be less accurate among members of racial and ethnic minority groups. This would have considerable implications for research on racial and ethnic disparities in cancer screening. OBJECTIVES To review the literature on the relationship between race/ethnicity and the accuracy of self-reported cancer screening behavior and develop a conceptual framework that would provide a deeper understanding of factors underlying this relationship. METHODS We developed a conceptual framework drawing from diverse literatures including validation studies examining the accuracy of self-reported cancer screening behaviors and articles on survey response bias. RESULTS AND CONCLUSIONS Evidence suggests that racial and ethnic minorities may be less likely to provide accurate reports of their cancer screening behavior and that overreporting may be particularly problematic. Research conducted in other areas suggests that these sources of measurement error may stem from cognitive and motivational processes and that they can be moderated by question wording and data collection characteristics. At this point, however, the quality of the evidence is not strong and more research is needed before definitive conclusions can be drawn.

Hospital Characteristics Associated with Timeliness of Care in Veterans with Lung Cancer

RATIONALE Timeliness is one of six important dimensions of health care quality recognized by the Institute of Medicine. OBJECTIVES To evaluate timeliness of lung cancer care and identify institutional characteristics associated with timely care within the Veterans Affairs (VA) health care system. METHODS We used data from a VA nation-wide retrospective chart review and an independent audit of VA cancer programs to examine the association between time to first treatment and potentially explanatory institutional characteristics (e.g., volume of lung cancer patients) for 2,372 veterans diagnosed with lung cancer between 1 January 2002 and 1 September 2005 at 127 VA medical centers. We developed linear mixed effects models to control for clustering of patients within hospitals and we stratified analyses by stage. MEASUREMENTS AND MAIN RESULTS Median time to treatment varied widely between (23 to 182 d) and within facilities. Median time to treatment was 90 days in patients with stage I or II cancer and 52 days in those with more advanced disease (P < 0.0001). Factors associated with shorter times to treatment included a nonacademic setting and the existence of a specialized diagnostic clinic (in patients with limited-stage disease), performing a patient flow analysis (in patients with advanced disease), and leadership beliefs about providing timely care (in both groups). However, institutional characteristics explained less than 1% of the observed variation in treatment times. CONCLUSIONS Time to lung cancer treatment in U.S. veterans is highly variable. The numerous institutional characteristics we examined explained relatively little of this variability, suggesting that patient, clinician, and/or unmeasured institutional characteristics may be more important determinants of timely care.

Role of quality measurement in inappropriate use of screening for colorectal cancer: retrospective cohort study

Objective To examine whether the age based quality measure for screening for colorectal cancer is associated with overuse of screening in patients aged 70-75 in poor health and underuse in those aged over age 75 in good health. Design Retrospective cohort study utilizing electronic data from the Veterans Affairs (VA) Health Care System, the largest integrated healthcare system in the United States. Setting VA Health Care System. Participants Veterans aged ≥50 due for repeat average risk colorectal cancer screening at a primary care visit in fiscal year 2010. Main outcome measures Completion of colonoscopy, sigmoidoscopy, or fecal occult blood testing within 24 months of the 2010 visit. Results 399 067 veterans met inclusion/exclusion criteria (mean age 67, 97% men). Of these, 38% had electronically documented screening within 24 months. In multivariable log binomial regression adjusted for Charlson comorbidity index, sex, and number of primary care visits, screening decreased markedly after the age of 75 (the age cut off used by the quality measure) (adjusted relative risk 0.35, 95% confidence interval 0.30 to 0.40). A veteran who was aged 75 and unhealthy (in whom life expectancy might be limited and screening more likely to result in net burden or harm) was significantly more likely to undergo screening than a veteran aged 76 and healthy (unadjusted relative risk 1.64, 1.36 to 1.97). Conclusions Specification of a quality measure can have important implications for clinical care. Future quality measures should focus on individual risk/benefit to ensure that patients who are likely to benefit from a service receive it (regardless of age), and that those who are likely to incur harm are spared unnecessary and costly care.

Mental health, frequency of healthcare visits, and colorectal cancer screening.

Background:Research regarding the association between mental health and colorectal cancer (CRC) screening has produced mixed results. Variations may be explained by methodology, including whether potential confounders such as frequency of healthcare visits are considered. Objective:We examined the association between mental health and CRC screening, before and after controlling for demographics, comorbidities, and outpatient visit frequency. Design:Observational study based on a retrospective cohort. Subjects:A total of 855 veterans receiving care at a Veterans Affairs Medical Center. Measures:Medical record data were used to assess CRC screening rates and mental health status (number of diagnoses and the presence of depression, anxiety, posttraumatic stress disorder, substance, or psychotic disorders). Logistic regression was used to estimate the association between mental health diagnoses and CRC screening, before and after controlling for covariates. Results:Bivariate analyses suggested that CRC screening rates were higher for patients with a history of one or more mental health diagnoses (57% vs. 47%, P < 0.01). However, adjusting for timing of mental health diagnosis and outpatient visit frequency resulted in significant negative associations between CRC screening and all measures of mental health except posttraumatic stress disorder. Conclusions:Estimates of the association between mental health and CRC screening that do not adjust for outpatient visit frequency may be misleading. Veterans with mental health diagnoses were significantly less likely to be screened for CRC than their counterparts with no mental health diagnoses and an equal number of outpatient visits.

Are gender differences in colorectal cancer screening rates due to differences in self-reporting?

OBJECTIVE Studies have found that women are less likely than men to undergo colorectal cancer (CRC) screening. While one source of these disparities may be gender differences in barriers and facilitators to screening, another may be differences in reporting bias. METHOD In this study of 345 male and female veterans, conducted in 2006 in Minneapolis, MN, we examined CRC screening adherence rates by gender using medical records and self-report and assessed whether any differences were due to reporting bias. RESULTS We found a significantly higher rate of colonoscopy use among men when using self-report data, but no significant differences in either overall or test-specific screening adherence when using medical record data. Analyses examining the prevalence and determinants of concordance between self-report and medical records screening revealed that compared to women, men were less accurate in reporting sigmoidoscopy and colonoscopy and over-reported screening by colonoscopy. Men were also more likely to have missing self-report data and how missing data were handled affected differences in screening behavior. Accuracy in screening behavior was not explained by demographic variables, good physical or mental health, or physician recommendation for screening. CONCLUSIONS Reported gender disparities in CRC screening adherence may be a result of reporting bias.

Timeliness Across the Continuum of Care in Veterans with Lung Cancer

Introduction: By providing timely care at all steps along the continuum of lung cancer care, providers may be able to limit disease progression before treatment and possibly improve clinical outcomes. This study examines the timeliness of key events in the process of care between initial radiograph and first treatment. Methods: Dates of key events were extracted from the medical records of 2463 veterans receiving lung cancer care at 133 Department of Veterans Affairs (VA) facilities. After reviewing their site’s abstraction results, facility leaders completed a survey on their perceptions of their local processes of lung cancer care. Results: Median time from first radiography to first treatment was 71 days. The longest intermediate time interval examined was between first treatment referral and first treatment (median = 12 days). Time from first to last diagnostic test was most variable (interquartile range = 0–27 days). We found a significant trend indicating that the time interval from first radiograph to treatment was shorter for patients with more advanced disease. This effect was also significant within six of the seven intermediate time intervals we examined. Survey responses indicated that the chart review process stimulated improvement activity. Conclusions: Although patients with earlier stage disease benefit more from treatment, they do not proceed as quickly through the continuum of care as patients with more advanced disease. By measuring variability in timeliness of care at multiple steps in the lung cancer care process, facilities may identify opportunities for improvement.

Five-year downstream outcomes following prostate-specific antigen screening in older men.

IMPORTANCE Despite ongoing controversies surrounding prostate-specific antigen (PSA) screening, many men 65 years or older undergo screening. However, few data exist that quantify the chain of events following screening in clinical practice to better inform decisions. OBJECTIVE To quantify 5-year downstream outcomes following a PSA screening result exceeding 4.0 ng/mL in older men. DESIGN AND SETTING Longitudinal cohort study in the national Veterans Affairs health care system. PARTICIPANTS In total, 295,645 men 65 years or older who underwent PSA screening in the Veterans Affairs health care system in 2003 and were followed up for 5 years using national Veterans Affairs and Medicare data. MAIN OUTCOME MEASURES Among men whose index screening PSA level exceeded 4.0 ng/mL, we determined the number who underwent prostate biopsy, were diagnosed as having prostate cancer, were treated for prostate cancer, and were treated for prostate cancer and were alive at 5 years according to baseline characteristics. Biopsy and treatment complications were also assessed. RESULTS In total, 25,208 men (8.5%) had an index PSA level exceeding 4.0 ng/mL. During the 5-year follow-up period, 8313 men (33.0%) underwent at least 1 prostate biopsy, and 5220 men (62.8%) who underwent prostate biopsy were diagnosed as having prostate cancer, of whom 4284 (82.1%) were treated for prostate cancer. Performance of prostate biopsy decreased with advancing age and worsening comorbidity (P < .001), whereas the percentage treated for biopsy-detected cancer exceeded 75% even among men 85 years or older, those with a Charlson-Deyo Comorbidity Index of 3 or higher, and those having low-risk cancer. Among men with biopsy-detected cancer, the risk of death from non-prostate cancer causes increased with advancing age and worsening comorbidity (P < .001). In total, 468 men (5.6%) had complications within 7 days after prostate biopsy. Complications of prostate cancer treatment included new urinary incontinence in 584 men (13.6%) and new erectile dysfunction 588 men (13.7%). CONCLUSIONS AND RELEVANCE Performance of prostate biopsy is uncommon in older men with abnormal screening PSA levels and decreases with advancing age and worsening comorbidity. However, once cancer is detected on biopsy, most men undergo immediate treatment regardless of advancing age, worsening comorbidity, or low-risk cancer. Understanding downstream outcomes in clinical practice should better inform individualized decisions among older men considering PSA screening.