Carol A. Carlson

Factors Associated with Racial/Ethnic Differences in Colorectal Cancer Screening

Introduction: Racial/ethnic differences in colorectal cancer (CRC) screening rates are thought to account, in part, for the racial/ethnic differences in CRC disease burden. The purpose of this study was to examine which factors mediate racial/ethnic differences in CRC screening. Methods: Five hundred sixty participants attending a primary care clinic, aged 50 to 80 years, and of African-American, Hispanic, or non-Hispanic white race/ethnicity were interviewed. The goal was to assess the contribution of sociodemographic characteristics, knowledge, beliefs about CRC, and the health care experience with their primary care doctor to racial/ethnic differences in CRC screening. The outcome variable was self-reported screening. All analyses were weighted; bivariate testing and multivariate logistic regression was conducted. Results: The response rate was 55.7%, with no sociodemographic differences noted between respondents and nonrespondents. Respondents were African-American (n = 194), Hispanic (n = 162), and non-Hispanic white (n = 204); 64.5% were aged 50 to 64 years; 63.1% were women; 96.9% were insured; and over half reported a total annual income of less than

Informed decision making changes test preferences for colorectal cancer screening in a diverse population.

25,000. Overall 62.5% were current with CRC screening: 67.5% of non-Hispanic whites, 54.3% of African-Americans, and 48.6% of Hispanics (P < .001). A doctors recommendation (odds ratio, 3.86); awareness of screening (odds ratio, 3.32); older age (odds ratio, 2.88); greater education (odds ratio, 2.02); and perceived susceptibility (odds ratio, 1.74) contributed to racial/ethnic differences in CRC screening. Conclusions: Interventions to address CRC screening disparities among racial/ethnic groups should focus on the health care setting and patient education about CRC screening; differences in attitudes and beliefs seem to be less important.

Development and Internal Validation of the Male Osteoporosis Risk Estimation Score

PURPOSE We wanted to better understand patient preferences and decision making about options for colorectal cancer screening. Consistency in patient preferences could improve patient-clinician communication about tests by simplifying and focusing discussions. METHODS In a cross-sectional sample of primary care patients, cognitive ranking tasks were used to estimate patient preferences for fecal occult blood testing, flexible sigmoidoscopy, colonoscopy, and double-contrast barium enema before and after consideration of 13 test attributes, such as accuracy and scientific evidence. Patients also ranked the 13 test attributes and attribute descriptions in terms of importance. Friedman’s nonparametric test was used to measure overall discrimination among items, and the average Pearson correlation coefficient (&rmacr;) among participants was used to measure the degree of consistency in choices. RESULTS Participants (n = 168) averaged 62.1 years of age, and 64.3% were of minority racial ethnicity. For test-specific attributes, preferences were for high test accuracy (r̄=0.63, P <.001), amount of colon examined (r̄=0.64, P <.001), strong scientific evidence for efficacy (r̄=0.59, P<.001), minimum discomfort (r̄=0.50, P <.001), and low risk of complications (r̄=0.38, P<.001). When all 13 attributes were considered together, agreement dropped (r̄=0.13, P<.001), but attributes considered most important for decision making were test accuracy, scientific evidence for efficacy, amount of colon examined, and need for sedation. Test preferences showed moderate agreement (r̄=0.20, P <.001), and choices were fairly consistent before and after exposure to test-specific attributes (κ=0.17, P = .007). Initially the modal choice was fecal occult blood testing (59%); however, after exposure to test specific attributes, the modal choice was colonoscopy (54%). CONCLUSION Participants were clear about the attributes that they prefer, but no single test has those attributes. Preferences were varied across participants and were not predictable; clinicians should discuss the full range of recommended tests for colorectal cancer with all patients.

Integrating Complementary and Alternative Medicine Into Conventional Primary Care: The Patient Perspective

PURPOSE We wanted to develop and validate a clinical prediction rule to identify men at risk for osteoporosis and subsequent hip fracture who might benefit from dual-energy x-ray absorptiometry (DXA). METHODS We used risk factor data from the National Health and Nutrition Examination Survey III to develop a best fitting multivariable logistic regression model in men aged 50 years and older randomized to either the development (n = 1,497) or validation (n = 1,498) cohorts. The best fitting model was transformed into a simplified scoring algorithm, the Male Osteoporosis Risk Estimation Score (MORES). We validated the MORES, comparing sensitivity, specificity, and area under the receiver operating characteristics (ROC) curve in the 2 cohorts and assessed clinical utility with an analysis of the number needed-to-screen (NNS) to prevent 1 additional hip fracture. RESULTS The MORES included 3 variables—age, weight, and history of chronic obstructive pulmonary disease—and showed excellent predictive validity in the validation cohort. A score of 6 or greater yielded an overall sensitivity of 0.93 (95% CI, 0.85–0.97), a specificity of 0.59 (95% CI, 0.56–0.62), and an area under the ROC curve of 0.832 (95% CI, 0.807–0.858). The overall NNS to prevent 1 additional hip fracture was 279 in a cohort of men representative of the US population. CONCLUSIONS Osteoporosis is a major predictor of hip fractures. Experts believe bisphosphonate treatment in men should yield results similar to that in women and reduce hip fracture rates associated with osteoporosis. In men aged 60 years and older, the MORES is a simple approach to identify men at risk for osteoporosis and refer them for confirmatory DXA scans.

Osteoporosis Risk Assessment and Ethnicity: Validation and Comparison of 2 Clinical Risk Stratification Instruments

OBJECTIVE The aim of this study was to explore perspectives on integrating complementary and alternative medicine (CAM) into the conventional primary care setting among patients treated at a large academic family medicine clinic in Texas. METHODS We developed and administered a multiple choice questionnaire to evaluate perspectives of 502 patients on integrating CAM into the conventional primary healthcare system. All collected data were statistically analyzed to evaluate responses. RESULTS Among study participants, 66% indicated that they had used CAM treatments during the past year, 77% responded that they would be interested in using CAM during the next year, and 55.4% replied that they would like CAM therapies to be provided in their primary care clinic. CONCLUSION The use of CAM in primary care settings in southern Texas is widespread. However, in this primary care setting, patients would like their family physician to provide and supervise these therapies. PRACTICE IMPLICATIONS Patients believe that there is an increased need for family physician involvement in providing and supervising CAM treatments. Our findings are preliminary but can provide a basis for multicenter, cross-cultural studies to further evaluate the patient perspective on the process of integrating CAM into the conventional primary healthcare system so that healthcare policy makers can better address public need.

Screening for Bipolar Disorder in Patients Treated for Depression in a Family Medicine Clinic

BACKGROUND: Dual energy x-ray absorptiometry (DXA), coupled with early treatment, may reduce morbidity and mortality associated with osteoporosis. Clinical tools to enhance selection of women for DXA screening have not been developed or validated in an ethnically diverse population.OBJECTIVE: To compare the performance of the osteoporosis risk assessment instrument (ORAI) and the simple calculated osteoporosis risk estimation (SCORE) instrument across 3 racial/ethnic groups to identify women who would benefit from DXA scans.DESIGN: Blinded comparison of the instruments in a cross-sectional sample.PARTICIPANTS: Two-hundred twenty-six postmenopausal women were recruited from a university-based family medicine clinic. Women with a prior diagnosis of osteoporosis or those taking bone active medications were excluded.MEASUREMENTS: Participants completed a questionnaire that contained the ORAI and the SCORE questions; 203 completed a DXA scan.RESULTS: The sensitivity and specificity for the ORAI (0.68, [0.49 to 0.88, 95% CI]; 0.66, [0.59 to 0.73, 95% CI]) and the SCORE instrument (0.54, [0.34 to 0.75, 95% CI]; 0.72, [0.65 to 0.78, 95% CI]) differed significantly from previous reports. Overall, the accuracy of the ORAI (66.5%) and SCORE instrument (70.0%) were similar (McNemar’s test P value=37). The accuracy between instruments differed significantly in African-American women (McNemar’s test, P value <.001). In African Americans, the SCORE instrument correctly identified more women without osteoporosis, but missed 70% of those with osteoporosis.CONCLUSIONS: The performance of the ORAI and SCORE instrument differed significantly from previous reports. Although both can reduce the use of DXA scans for screening for osteoporosis, lower sensitivities resulted in underrecognition of osteoporosis and may limit their clinical usefulness in an ethnically diverse population.