Bruce S. Ling

Family history and colorectal cancer screening: A survey of physician knowledge and practice patterns

OBJECTIVES:Risk stratification is essential to effective implementation of colorectal cancer (CRC) screening strategies. The objectives of this study were to assess and compare the current knowledge and practice patterns of gastroenterologists and primary care physicians regarding familial risk of CRC.METHODS:We conducted a survey of regional gastroenterologists and a sample of university- and community-based primary care physicians. The survey instrument assessed physician knowledge of screening recommendations and current practices for individuals with family histories of CRC, adenomatous polyps (APs), familial adenomatous polyposis (FAP), and hereditary nonpolyposis cancer (HNPCC). The instrument also elicited data about familial risk assessment, documentation, and notification of at-risk family members.RESULTS:Thirty-five gastroenterologists (65%) and 58 primary care physicians (92%) completed the survey. Most gastroenterologists and primary care physicians (85% vs 72%) chose age 40 as the appropriate age to begin screening for a family history of CRC, but relatively few (37% vs 36%) recommended screening at age 40 for a family history of APs. Gastroenterologists were significantly more likely to recommend screening for FAP at puberty (80% vs 27%, p < 0.001) and for HNPCC at age 25 (73% vs 50%, p = 0.04). Colonoscopy was the preferred screening strategy by both groups for family histories of CRC (97%), HNPCC (97%), and APs (77%); primary care physicians also preferred colonoscopy for family histories of CRC (72%) and HNPCC (76%) but flexible sigmoidoscopy plus fecal occult blood testing for a family history of APs (38%). Gastroenterologists were more likely to recommend genetic testing for persons at risk of FAP (91% vs 71%, p = 0.03) and HNPCC (72% vs 57%, p = 0.18), routinely inquire about a family history of CRC or APs (93% vs 63%, p < 0.001), and recommend notification of at-risk first-degree relatives with family histories of CRC (94% vs 55%, p < 0.001) or AP (53% vs 6%, p < 0.001).CONCLUSION:Although gastroenterologists are more likely than primary care physicians to elicit a family history of colorectal neoplasia and implement appropriate screening strategies, overall compliance with recommended guidelines and notification of at-risk relatives are suboptimal. Novel approaches for improving awareness of the available screening guidelines are needed.

Patients with Complex Chronic Diseases: Perspectives on Supporting Self-Management

A Complex Chronic Disease (CCD) is a condition involving multiple morbidities that requires the attention of multiple health care providers or facilities and possibly community (home)-based care. A patient with CCD presents to the health care system with unique needs, disabilities, or functional limitations. The literature on how to best support self-management efforts in those with CCD is lacking. With this paper, the authors present the case of an individual with diabetes and end-stage renal disease who is having difficulty with self-management. The case is discussed in terms of intervention effectiveness in the areas of prevention, addiction, and self-management of single diseases. Implications for research are discussed.

Behind closed doors: Physician-patient discussions about colorectal cancer screening

BACKGROUNDDespite the availability of multiple effective screening tests for colorectal cancer, screening rates remain suboptimal. The literature documents patient preferences for different test types and recommends a shared decision-making approach for physician-patient colorectal cancer screening (CRCS) discussions, but it is unknown whether such communication about CRCS preferences and options actually occurs in busy primary-care settings.OBJECTIVEDescribe physician-patient CRCS discussions during a wellness visit.DESIGNCross-sectional; patients audio-recorded with physicians.PARTICIPANTSA subset of patients (N = 64) participating in a behavioral intervention trial designed to increase CRCS who completed a wellness visit during the trial with a participating physician (N = 8).APPROACHTranscripts were analyzed using qualitative methods.RESULTSPhysicians in this sample consistently recommended CRCS, but focused on colonoscopy. Physicians did not offer a fecal occult blood test alone as a screening choice, which may have created missed opportunities for some patients to get screened. In this single visit, physicians’ communication processes generally precluded discussion of patients’ test preferences and did not facilitate shared decision-making. Patients’ questions indicated their interest in different CRCS test types and appeared to elicit more information from physicians. Some patients remained resistant to CRCS after discussing it with a physician.CONCLUSIONIf a preference for colonoscopy is widespread among primary-care physicians, the implications for intervention are either to prepare patients for this preference or to train physicians to offer options when recommending screening to patients.

Informed Decision-Making and Colorectal Cancer Screening : Is it Occurring in Primary Care?

Background:Current recommendations advise patients to participate in the decision-making for selecting a colorectal cancer (CRC) screening option. The degree to which providers communicate the information necessary to prepare patients for participation in this process is not known. Objective:To assess the level of informed decision-making occurring during actual patient-provider communications on CRC screening and test for the association between informed decision-making and screening behavior. Research Design:Observational study of audiotaped clinic visits between patients and their providers in the primary care clinic at a Veterans Administration Medical Center. Subjects:Male patients, age 50–74 years, presenting to a primary care visit at the study site. Measures:The Informed Decision-Making (IDM) Model was used to code the audiotapes for 9 elements of communication that should occur to prepare patients for participation in decision-making. The primary outcome is completion of CRC screening during the study period. Results:The analytic cohort consisted of 91 patients due for CRC screening who had a test ordered at the visit. Six of the 9 IDM elements occurred in ≤20% of the visits with none addressed in ≥50%. CRC screening occurred less frequently for those discussing “pros and cons” (12% vs. 46%, P = 0.01) and “patient preferences” (6% vs. 47%, P = 0.001) compared with those who did not. Conclusions:We found that a lack of informed decision-making occurred during CRC screening discussions and that particular elements of the process were negatively associated with screening. Further research is needed to better understand the effects of informed decision-making on screening behavior.

Relationship of communication and information measures to colorectal cancer screening utilization: results from HINTS.

Utilization of colorectal cancer screening tests is suboptimal. Knowledge of colorectal cancer screening has been associated with completion of screening. Thus, increasing awareness of colorectal cancer screening may lead to significant improvements in screening rates. We assessed for the association among provider–patient interaction, information-seeking patterns, sources of information, trust in cancer information, and Internet usage on colorectal cancer screening behavior using data obtained by the Health Information National Trends Survey (HINTS). From a cohort of 2,670 respondents greater than 50 years of age, we found that they (1) desired cancer information from personalized reading materials, meeting in person with a health care professional, and published materials; and (2) had great trust of information from their provider. Having trust in cancer information from the doctor or other health care professional was most predictive (OR 2.08, 95% CI 1.49–2.94) of being up to date. Other predictive factors include having a desire for cancer information from personalized reading materials (OR 1.56, 95% CI 1.24–1.95) and using the Internet from home (OR 1.32, 95% CI 1.04–1.67). We conclude that personalized communications from a health care provider are desired and trusted. Another promising information delivery approach is the Internet. Dedicated efforts using these approaches for information exchange may be most beneficial toward increasing utilization of colorectal cancer screening.

Physicians Encouraging Colorectal Screening: A Randomized Controlled Trial of Enhanced Office and Patient Management on Compliance With Colorectal Cancer Screening

BACKGROUND Colorectal cancer screening is underused. Our objective was to evaluate methods for promoting colorectal cancer screening in primary care practice. METHODS A 2 x 2 factorial randomized clinical trial measured the effects of a tailored vs nontailored physician recommendation letter and an enhanced vs nonenhanced physician office and patient management intervention on colorectal cancer screening adherence. The enhanced and nonenhanced physician office and patient management interventions varied the amount of external support to help physician offices develop and implement colorectal cancer screening programs. The study included 10 primary care physician office practices and 599 screen-eligible patients aged 50 to 79 years. The primary end point was medical-record-verified flexible sigmoidoscopy or colonoscopy. Statistical end-point analysis (according to randomization intent) used generalized estimating equations to account for correlated outcomes according to physician group. RESULTS During a 1-year period, endoscopy in the lower gastrointestinal tract (lower endoscopy) occurred in 289 of 599 patients (48.2%). This finding included the following rates of lower endoscopy: 81 of 152 patients (53.3%) in the group that received the tailored letter and enhanced management; 103 of 190 (54.2%) in the group that received the nontailored letter and enhanced management; 58 of 133 (43.6%) in the group that received the tailored letter and nonenhanced management; and 47 of 124 (37.9%) in the group that received the nontailored letter and nonenhanced management. Enhanced office and patient management increased the odds of completing a colonoscopy or flexible sigmoidoscopy by 1.63-fold (95% confidence interval, 1.11-2.41; P = .01). However, the tailored letter increased the odds of completion by only 1.08-fold (95% confidence interval, 0.72-1.62; P = .71). CONCLUSIONS Approximately one-half of the screen-eligible primary medical care patients aged 50 to 79 years obtained lower endoscopic colorectal cancer screening within 1 year of recommendation. An enhanced office and patient management system significantly improved colorectal cancer screening adherence. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00327457.

Using the Transtheoretical Model to Stage Screening Behavior for Colorectal Cancer

This study sought to describe the colorectal cancer (CRC)-screening behavior of a population of two lower income communities near Pittsburgh, Pennsylvania. The transtheoretical model was used to characterize individuals according to their stage of readiness to engage in one of two recommended CRC screening tests—the Fecal Occult Blood Test (FOBT) or Flexible Sigmoidoscopy (FSG) test. A telephone survey was conducted of 50- to 79-year-old men and women in Aliquippa and Clairton in the spring of 1999. Analyses based on 414 survey respondents showed associations between FOBT or FSG behavioral stage and factors including gender, age, recent doctor checkup, chronic need for prescription medications, history of cervical Pap smear testing, history of prostate-specific antigen blood testing, and prior doctor recommendation in favor of FOBT or FSG testing. This study appears to be one of the first applications of this theory to understanding CRC screening behavior in a community intervention.

When pregnant patients disclose substance use: missed opportunities for behavioral change counseling.

OBJECTIVE The first obstetric visit is an opportunity to provide counseling to women with substance abuse risks, including smoking, drug use, and alcohol use. Little is known about how obstetric care providers and patients discuss these issues. Our objective was to examine patient-provider communication about substance use behaviors during these visits. METHODS We audio-taped and transcribed verbatim first prenatal visits in an outpatient hospital clinic, then qualitatively analyzed them for content and process of communication using modified grounded theory methods. RESULTS Twenty-nine providers (21 residents, 5 midwives, 3 nurse practitioners) and 51 patients participated. Twenty-five patients were smokers, 4 used alcohol, and 11 used drugs. Provider responses to smoking disclosures included discussions of risks, encouragement to quit-cut down, affirmation of attempts to quit-cut down, and referral to smoking cessation programs. Responses to alcohol or drug disclosures included only a general statement regarding risks and referral to genetics. CONCLUSION Providers were less attentive to alcohol and drugs than smoking where they had pre-established patterns of response. PRACTICE IMPLICATIONS Providers should discuss behavioral change strategies and motivations with pregnant patients who use drugs and/or alcohol as well as those who smoke.

A population-based, community estimate of total colon examination: the impact on compliance with screening for colorectal cancer.

OBJECTIVE:Colorectal cancer screening is underutilized. Total colon examination (TCE), such as with colonoscopy, can have a significant effect on the measured compliance with screening, as colonoscopy may be able to be performed as infrequently as once every 10 yr. In a population-based survey we determined the prevalence and validated the self-reporting of TCE and assessed its impact on compliance with screening.METHODS:We interviewed an age- and sex-stratified random sample of 50- to 79-yr-old residents in two communities in southwestern Pennsylvania. Subjects reported ever having had and duration since last use of fecal occult blood testing (FOBT), flexible sigmoidoscopy (FS), rigid proctoscopy, barium enema, and colonoscopy. Self-reports of colorectal testing were validated via retrieval of procedure reports.RESULTS:Out of 1223 individuals sampled, 496 completed a telephone interview (40.6% overall and 58.3% of eligible contacts). In those without personal or family histories of colorectal cancer or personal histories of polyps (n = 377), 50%, 19.6%, 39.8%, and 17.5% reported ever having had FOBT, FS, barium enema, and colonoscopy, respectively. Thirty-one percent reported having FOBT within the previous year or FS within the previous 5 yr. Including TCE within the previous 5 yr increased the measured compliance to 39.7%. Compliance was significantly greater among subjects with family histories of colorectal cancer (62.9% vs 39.7%, odds ratio = 2.6, 95% CI = 1.3–5.2). Self-reports of recent colonoscopy were verified in 29 of 35 instances (83%).CONCLUSION:The prevalence of TCE in this population was significant, and including TCE substantially increased measured compliance with colorectal cancer screening. Self-reported use of colonoscopy was validated as accurate.

An affective booster moderates the effect of gain- and loss-framed messages on behavioral intentions for colorectal cancer screening

Previous research has demonstrated that loss-framed messages are more effective than gain-framed messages in motivating detection behaviors such as screening. The present study examined whether affective context moderates the degree to which message frame is associated with behavioral intentions to engage in colorectal cancer screening. In particular, we buttressed a framing manipulation with an “affective booster” to increase anticipated and anticipatory emotions associated with the framed messages. Consistent with previous research, we found that loss-framed messages are more effective in increasing intentions to screen. However, we found that among individuals who received gain-framed messages (but not loss-framed messages), the affective booster increased message persuasiveness. This effect on intentions was partially mediated by self-efficacy for engaging in screening. This study indicates that in the presence of emotional boosters, loss-framed messages may lose their advantage over gain-framed messages in motivating detection behaviors, and that self-efficacy may partially explain these effects.