Brian Stello

Variation in Colorectal Cancer Screening Steps in Primary Care Basis for Practice Improvement

No published research has assessed the specific steps that primary care practices actually take to carry out screening for colorectal cancer (CRC). A written survey was distributed to clinicians and staff at 15 primary care practices to determine whether they perceived that personnel in their practices performed a series of 4 steps associated with screening colonoscopy and 7 steps associated with stool blood test screening. For each discrete step, the percentage of respondents from each practice who indicated that a given step is performed in that practice was calculated along with the mean of practice percentages. Survey results indicate wide variation in the degree to which these screening steps are performed across the 15 practices.  Variation was greater for steps that involved contacting nonresponders (reminders), scheduling, and rescheduling. Survey responses suggest substantial variation and much room for improvement in practice performance of evidence-based steps in the CRC screening process.

Colorectal cancer screening in the framework of the medical home model: findings from focus groups and interviews.

A recent report from a survey of 15 primary care practices revealed considerable variability and much room for improvement in aspects of primary care practice that are associated with increased colorectal cancer screening rates. There was low utilization of patient reminders, tracking of test completion, rescheduling of missed appointments, and inconsistent follow-up of positive stool blood tests. Qualitative data collected in the same study provide insights into how the practices operated. Focus group discussions with the clinicians and staff of the practices and key informant interviews with office managers support the survey findings by shedding light on a lack of office policies and systems. Many practices lacked a systematic way to identify patients who were not up to date on screening while they were visiting the practice, thereby passing up the best opportunity to reach them. These findings are not consistent with the patient-centered medical home model.

Factors Influencing Participation in Clinical Trials: Emergency Medicine vs. Other Specialties.

Introduction This study investigated factors that influence emergency medicine (EM) patients’ decisions to participate in clinical trials and whether the impact of these factors differs from those of other medical specialties. Methods A survey was distributed in EM, family medicine (FM), infectious disease (ID), and obstetrics/gynecology (OB/GYN) outpatient waiting areas. Eligibility criteria included those who were 18 years of age or older, active patients on the day of the survey, and able to complete the survey without assistance. We used the Kruskal-Wallis test and ordinal logistic regression analyses to identify differences in participants’ responses. Results A total of 2,893 eligible subjects were approached, and we included 1,841 surveys in the final analysis. Statistically significant differences (p≤0.009) were found for eight of the ten motivating factors between EM and one or more of the other specialties. Regardless of a patient’s gender, race, and education, the relationship with their doctor was more motivating to patients seen in other specialties than to EM patients (FM [odds ratio {OR}:1.752, 95% confidence interval {CI}{1.285–2.389}], ID [OR:3.281, 95% CI{2.293–4.695}], and OB/GYN [OR:2.408, 95% CI{1.741–3.330}]). EM’s rankings of “how well the research was explained” and whether “the knowledge learned would benefit others” as their top two motivating factors were similar across other specialties. All nine barriers showed statistically significant differences (p≤0.008) between EM and one or more other specialties. Participants from all specialties indicated “risk of unknown side effects” as their strongest barrier. Regardless of the patients’ race, “time commitment” was considered to be more of a barrier to other specialties when compared to EM (FM [OR:1.613, 95% CI{1.218–2.136}], ID [OR:1.340, 95% CI{1.006–1.784}], or OB/GYN [OR:1.901, 95% CI{1.431–2.526}]). Among the six resources assessed that help patients decide whether to participate in a clinical trial, only one scored statistically significantly different for EM (p<0.001). EM patients ranked “having all material provided in my own language” as the most helpful resource. Conclusion There are significant differences between EM patients and those of other specialties in the factors that influence their participation in clinical trials. Providing material in the patient’s own language, explaining the study well, and elucidating how their participation might benefit others in the future may help to improve enrollment in EM-based clinical trials.

Implementation of Technology-based Patient Engagement Strategies within Practice-based Research Networks

Background: Technology-based patient engagement strategies (such as patient portals) are increasingly available, yet little is known about current use and barriers within practice-based research networks (PBRNs). PBRN directors have unique opportunities to inform the implementation of patient-facing technology and to translate these findings into practice. Methods: PBRN directors were queried regarding technology-based patient engagement strategies as part of the 2015 CAFM Educational Research Alliance (CERA) survey of PBRN directors. A total of 102 PBRN directors were identified via the Agency for Healthcare Research and Qualitys registry; 54 of 96 eligible PBRN directors completed the survey, for a response rate of 56%. Results: Use of technology-based patient engagement strategies within PBRNs was limited, with less than half of respondents reporting experience with the most frequently named tools (risk assessments/decision aids). Information technology (IT) support was the top barrier, followed by low rates of portal enrollment. For engaging participant practices, workload and practice leadership were cited as most important, with fewer respondents noting concerns about patient privacy. Discussion: Given limited use of patient-facing technologies, PBRNs have an opportunity to clarify the optimal use of these strategies. Providing IT support and addressing clinician concerns regarding workload may facilitate the inclusion of innovative technologies in PBRNs.

Clinician-Reported Barriers to Group Visit Implementation

Background: Group visits have been shown to improve disease-oriented outcomes and satisfaction, yet many clinicians have not incorporated them into practice. We aimed to identify clinician-reported barriers that preclude clinicians from implementing group visits. Methods: Primary care physicians from one practice-based research network were surveyed regarding their experience with and barriers to group visits. The survey, developed for this study, was mailed to 246 clinicians. Results: Of 107 respondents (44% response rate), those in practice <10 years were significantly more likely to have had group visit experience than those with >10 years of experience. For those without prior group visit experience, training was named as the top barrier to incorporating group visits. Those with group visit experience named staffing concerns and recruitment as the top barriers to group visit implementation. Conclusions: Primary care clinicians without prior group visit experience were less likely to endorse group visits. Addressing the modifiable barriers may enhance the incorporation of group visits into practice.

Patient-Reported Barriers and Limitations to Attending Diabetes Group Visits.

Purpose: Through this exploratory study, we sought to understand why group visit participation is low among adult patients with type 2 diabetes. Methods: Eligible study participants included adult patients with type 2 diabetes. After a pilot survey was sent to a random sample of 48 patients, the remaining 187 eligible patients were invited to complete a revised version of the survey. Results: Most frequently cited reasons for not attending group visits included diabetes under control, work and/or other responsibilities, and time barriers. There was variability in the desired time for the visits, though the majority of patients preferred evening visits. While some patients reported copays as a challenge, the likelihood of attending did not decrease for this subgroup. Most patients surveyed (54%) indicated interest in diabetes group visits. Conclusion: Implementing strategies to address the patient-identified system barriers (eg, time, transportation, and copays) may increase participation in diabetes group visits.

Impact of Race Versus Education and Race Versus Income on Patients’ Motivation to Participate in Clinical Trials

Our study investigates whether levels of motivation and barriers to participation in clinical trials vary with patients’ education and income. A self-administered survey asked outpatients to rank potential influential factors on a “0” to “4” significance scale for their motivation to participate in clinical trials. Principal component analysis (PCA), analysis of variance (ANOVA), Kruskal-Wallis, and Mann-Whitney U tests analyzed the impact of race, education, and income on their motivation to participate. Analysis included 1841 surveys; most respondents had a high school education or some college, and listed annual income < 

Exploring Health Beliefs Among Hispanic Adults with Prediabetes

30,000. There was a significant interaction between race and income on our motivation scale 1 scores (p = .0261). Compared with their counterparts, subjects with less education/lower income ranked monetary compensation (p = .0420 and p < .0001, respectively) as a higher motivator. Minorities and patients with less education and lower income appear to be more influenced by their desire to please the doctor, the race and sex of the doctor, and the language spoken by the doctor being the same as theirs. For all races, education appeared to have a direct relationship with motivation to participate, except for African-Americans, whose motivation appeared to decline with more education. Income appeared to have an inverse relationship with motivation to participate for all races.

Setting the Agenda for Patient-centered Care: Incorporation of Patient-reported Outcome Measures

Diabetes and prediabetes are increasing in prevalence, corresponding to epidemic rates of obesity. Hispanic adults with prediabetes are 1.7 times more likely than non-Hispanic whites to progress to diabetes. We set out to understand health beliefs of Hispanic adults and, with that knowledge, facilitate tailored messaging to promote patient activation and lifestyle change. Using the Risk Perception Survey for Developing Diabetes along with demographic and lifestyle intervention interest questions, a 34-question survey was mailed to a registry of Hispanic adults with a diagnosis of prediabetes and an HbA1c between 5.7 and 6.4% (N = 414). Despite more than three-quarters of respondents (n = 92; 77%) indicating they had prior knowledge of their diagnosis, overall diabetes risk knowledge was low. A significant difference in diabetes risk knowledge was found between groups stratified by education level. High scores in personal control and worry were reported. Respondents overwhelmingly reported interest in exercise (n = 92; 77%) and healthy eating interventions (n = 60; 50%) over technology-based interventions. High levels of worry and personal control, combined with low to intermediate levels of risk knowledge, indicate an opportunity for education and activation in this community. Healthy eating and exercise programs are possible interventions that may slow the progression from prediabetes to diabetes.

Racial Differences Among Factors Associated with Participation in Clinical Research Trials

Careyva BA1,2*, Singh J3, Goldberg A1,2, Johnson M1 and Stello B1 1Department of Family Medicine, Allentown, PA, USA 2Morsani College of Medicine, University of South Florida, Tampa, Florida, USA 3Lehigh University, Bethlehem, PA, USA *Corresponding author: Beth A Careyva, MD, Department of Family Medicine, Lehigh Valley Health Network, 707 Hamilton St., 8th Floor, P.O. Box 1806, Allentown, PA 18105-1806, USA, Tel: +484-862-3059, Fax: +484-862-3059, E-mail: beth_a.careyva@lvhn.org