Donald Haverkamp

Regional differences in colorectal cancer incidence, stage, and subsite among American Indians and Alaska Natives, 1999-2004.

Colorectal cancer (CRC) is a leading cause of cancer morbidity and mortality for American Indians and Alaska Natives (AI/ANs), but misclassification of race causes underestimates of disease burden.

Geographic Variation in Colorectal Cancer Incidence and Mortality, Age of Onset, and Stage at Diagnosis Among American Indian and Alaska Native People, 1990–2009

OBJECTIVES We characterized estimates of colorectal cancer (CRC) in American Indians/Alaska Natives (AI/ANs) compared with Whites using a linkage methodology to improve AI/AN classification in incidence and mortality data. METHODS We linked incidence and mortality data to Indian Health Service enrollment records. Our analyses were restricted to Contract Health Services Delivery Area counties. We analyzed death and incidence rates of CRC for AI/AN persons and Whites by 6 regions from 1999 to 2009. Trends were described using linear modeling. RESULTS The AI/AN colorectal cancer incidence was 21% higher and mortality 39% higher than in Whites. Although incidence and mortality significantly declined among Whites, AI/AN incidence did not change significantly, and mortality declined only in the Northern Plains. AI/AN persons had a higher incidence of CRC than Whites in all ages and were more often diagnosed with late stage CRC than Whites. CONCLUSIONS Compared with Whites, AI/AN individuals in many regions had a higher burden of CRC and stable or increasing CRC mortality. An understanding of the factors driving these regional disparities could offer critical insights for prevention and control programs.

The last frontier: innovative efforts to reduce colorectal cancer disparities among the remote Alaska Native population

BACKGROUND The Alaska Native (AN) population experiences twice the incidence and mortality of colorectal cancer (CRC) as does the U.S. white population. CRC screening allows early detection and prevention of cancer. OBJECTIVE We describe pilot projects conducted from 2005 to 2010 to increase CRC screening rates among AN populations living in rural and remote Alaska. DESIGN Projects included training rural mid-level providers in flexible sigmoidoscopy, provision of itinerant endoscopy services at rural tribal health facilities, the creation and use of a CRC first-degree relative database to identify and screen individuals at increased risk, and support and implementation of screening navigator services. SETTING Alaska Tribal Health System. PATIENTS AN population. INTERVENTIONS Itinerant endoscopy, patient navigation. MAIN OUTCOME MEASUREMENTS AN patients screened for CRC, colonoscopy quality measures. RESULTS As a result of these ongoing efforts, statewide AN CRC screening rates increased from 29% in 2000 to 41% in 2005 before the initiation of these projects and increased to 55% in 2010. The provision of itinerant CRC screening clinics increased rural screening rates, as did outreach to average-risk and increased-risk (family history) ANs by patient navigators. However, health care system barriers were identified as major obstacles to screening completion, even in the presence of dedicated patient navigators. LIMITATIONS Continuing challenges include geography, limited health system capacity, high staff turnover, and difficulty getting patients to screening appointments. CONCLUSIONS The projects described here aimed to increase CRC screening rates in an innovative and sustainable fashion. The issues and solutions described may provide insight for others working to increase screening rates among geographically dispersed and diverse populations.

Causes and Disparities in Death Rates Among Urban American Indian and Alaska Native Populations, 1999-2009

OBJECTIVES To characterize the leading causes of death for the urban American Indian/Alaska Native (AI/AN) population and compare with urban White and rural AI/AN populations. METHODS We linked Indian Health Service patient registration records with the National Death Index to reduce racial misclassification in death certificate data. We calculated age-adjusted urban AI/AN death rates for the period 1999-2009 and compared those with corresponding urban White and rural AI/AN death rates. RESULTS The top-5 leading causes of death among urban AI/AN persons were heart disease, cancer, unintentional injury, diabetes, and chronic liver disease and cirrhosis. Compared with urban White persons, urban AI/AN persons experienced significantly higher death rates for all top-5 leading causes. The largest disparities were for diabetes and chronic liver disease and cirrhosis. In general, urban and rural AI/AN persons had the same leading causes of death, although urban AI/AN persons had lower death rates for most conditions. CONCLUSIONS Urban AI/AN persons experience significant disparities in death rates compared with their White counterparts. Public health and clinical interventions should target urban AI/AN persons to address behaviors and conditions contributing to health disparities.

A survey of indian health service and tribal health providers' colorectal cancer screening knowledge, perceptions, and practices

Background. Provider recommendation is critical for colorectal cancer (CRC) screening participation, yet few data exist on practices of providers serving American Indians and Alaska Natives. We examined Indian Health Service (IHS) and tribal provider practices, beliefs about screening efficacy, and perceptions of barriers.Methods. We developed a Web-based questionnaire and recruited respondents via electronic distribution lists. We generated descriptive statistics by region, provider type, and workplace setting.Results. Most respondents (77%) recommend starting CRC screening of average-risk patients at age 50; however, 22% recommend flexible sigmoidoscopy and 43% colonoscopy at intervals inconsistent with national guidelines. Of those recommending fecal occult blood test (FOBT), 23% use a single, in-office FOBT card as their only FOBT method. Respondents reported barriers to screening to include underutilized reminder systems and inadequate resources.Conclusions. Indian Health Service/tribal providers are knowledgeable about when to begin CRC screening; however, education about the appropriate use and frequency of CRC tests is needed.

Designing Colorectal Cancer Screening Decision Support: A Cognitive Engineering Enterprise

Adoption of clinical decision support has been limited. Important barriers include an emphasis on algorithmic approaches to decision support that do not align well with clinical work flow and human decision strategies, and the expense and challenge of developing, implementing, and refining decision support features in existing electronic health records (EHRs). We applied decision-centered design to create a modular software application to support physicians in managing and tracking colorectal cancer screening. Using decision-centered design facilitates a thorough understanding of cognitive support requirements from an end user perspective as a foundation for design. In this project, we used an iterative design process, including ethnographic observation and cognitive task analysis, to move from an initial design concept to a working modular software application called the Screening & Surveillance App. The beta version is tailored to work with the Veterans Health Administration’s EHR Computerized Patient Record System (CPRS). Primary care providers using the beta version Screening & Surveillance App more accurately answered questions about patients and found relevant information more quickly compared to those using CPRS alone. Primary care providers also reported reduced mental effort and rated the Screening & Surveillance App positively for usability.

Comparison of fecal occult blood tests for colorectal cancer screening in an Alaska Native population with high prevalence of Helicobacter pylori infection, 2008-2012.

Introduction Alaska Native colorectal cancer (CRC) incidence and mortality rates are the highest of any ethnic/racial group in the United States. CRC screening using guaiac-based fecal occult blood tests (gFOBT) are not recommended for Alaska Native people because of false-positive results associated with a high prevalence of Helicobacter pylori-associated hemorrhagic gastritis. This study evaluated whether the newer immunochemical FOBT (iFOBT) resulted in a lower false-positive rate and higher specificity for detecting advanced colorectal neoplasia than gFOBT in a population with elevated prevalence of H. pylori infection. Methods We used a population-based sample of 304 asymptomatic Alaska Native adults aged 40 years or older undergoing screening or surveillance colonoscopy (April 2008–January 2012). Results Specificity differed significantly (P < .001) between gFOBT (76%; 95% CI, 71%–81%) and iFOBT (92%; 95% CI, 89%–96%). Among H. pylori-positive participants (54%), specificity of iFOBT was even higher (93% vs 69%). Overall, sensitivity did not differ significantly (P = .73) between gFOBT (29%) and iFOBT (36%). Positive predictive value was 11% for gFOBT and 32% for iFOBT. Conclusion The iFOBT had a significantly higher specificity than gFOBT, especially in participants with current H. pylori infection. The iFOBT represents a potential strategy for expanding CRC screening among Alaska Native and other populations with elevated prevalence of H. pylori, especially where access to screening endoscopy is limited.

A Process Evaluation of the Alaska Native Colorectal Cancer Family Outreach Program

This article presents the results of a process evaluation of the Alaska Native (AN) Colorectal Cancer (CRC) Family Outreach Program, which encourages CRC screening among AN first-degree relatives (i.e., parents, siblings, adult children; hereafter referred to as relatives) of CRC patients. Among AN people incidence and death rates from CRC are the highest of any ethnic/racial group in the United States. Relatives of CRC patients are at increased risk; however, CRC can be prevented and detected early through screening. The evaluation included key informant interviews (August to November 2012) with AN and non-AN stakeholders and program document review. Five key process evaluation components were identified: program formation, evolution, outreach responses, strengths, and barriers and challenges. Key themes included an incremental approach that led to a fully formed program and the need for dedicated, culturally competent patient navigation. Challenges included differing relatives’ responses to screening outreach, health system data access and coordination, and the program impact of reliance on grant funding. This program evaluation indicated a need for more research into motivating patient screening behaviors, electronic medical records systems quality improvement projects, improved data-sharing protocols, and program sustainability planning to continue the dedicated efforts to promote screening in this increased risk population.

Incidence of primary liver cancer in American Indians and Alaska Natives, US, 1999–2009

PurposeTo evaluate liver cancer incidence rates and risk factor correlations in non-Hispanic AI/AN populations for the years 1999–2009.MethodsWe linked data from 51 central cancer registries with the Indian Health Service patient registration databases to improve identification of the AI/AN population. Analyses were restricted to non-Hispanic persons living in Contract Health Service Delivery Area counties. We compared age-adjusted liver cancer incidence rates (per 100,000) for AI/AN to white populations using rate ratios. Annual percent changes (APCs) and trends were estimated using joinpoint regression analyses. We evaluated correlations between regional liver cancer incidence rates and risk factors using Pearson correlation coefficients.ResultsAI/AN persons had higher liver cancer incidence rates than whites overall (11.5 versus 4.8, RR = 2.4, 95% CI 2.3–2.6). Rate ratios ranged from 1.6 (Southwest) to 3.4 (Northern Plains and Alaska). We observed an increasing trend among AI/AN persons (APC 1999–2009 = 5%). Rates of distant disease were higher in the AI/AN versus white population for all regions except Alaska. Alcohol use (r = 0.84) and obesity (r = 0.79) were correlated with liver cancer incidence by region.ConclusionsFindings highlight disparities in liver cancer incidence between AI/AN and white populations and emphasize opportunities to decrease liver cancer risk factor prevalence.

Influences and Practices in Colorectal Cancer Screening Among Health Care Providers Serving Northern Plains American Indians, 2011–2012

Introduction The epidemiology of colorectal cancer, including incidence, mortality, age of onset, stage of diagnosis, and screening, varies regionally among American Indians. The objective of the Improving Northern Plains American Indian Colorectal Cancer Screening study was to improve understanding of colorectal cancer screening among health care providers serving Northern Plains American Indians. Methods Data were collected, in person, from a sample of 145 health care providers at 27 health clinics across the Northern Plains from May 2011 through September 2012. Participants completed a 32-question, self-administered assessment designed to assess provider practices, screening perceptions, and knowledge. Results The proportion of providers who ordered or performed at least 1 colorectal cancer screening test for an asymptomatic, average-risk patient in the previous month was 95.9% (139 of 145). Of these 139 providers, 97.1% ordered colonoscopies, 12.9% ordered flexible sigmoidoscopies, 73.4% ordered 3-card, guaiac-based, fecal occult blood tests, and 21.6% ordered fecal immunochemical tests. Nearly two-thirds (64.7%) reported performing in-office guaiac-based fecal occult blood tests using digital rectal examination specimens. Providers who reported receiving a formal update on colorectal cancer screening during the previous 24 months were more likely to screen using digital rectal exam specimens than providers who had received a formal update on colorectal cancer screening more than 24 months prior (73.9% vs 56.9%, respectively, χ2 = 4.29, P = .04). Conclusion Despite recommendations cautioning against the use of digital rectal examination specimens for colorectal cancer screening, the practice is common among providers serving Northern Plains American Indian populations. Accurate up-to-date, ongoing education for patients, the community, and health care providers is needed.