M. Rosario Ferreira

Health Care Provider-Directed Intervention to Increase Colorectal Cancer Screening Among Veterans: Results of a Randomized Controlled Trial

PURPOSE Colorectal cancer screening is the most underused cancer screening tool in the United States. The purpose of this study was to test whether a health care provider-directed intervention increased colorectal cancer screening rates. PATIENTS AND METHODS The study was a randomized controlled trial conducted at two clinic firms at a Veterans Affairs Medical Center. The records of 5,711 patients were reviewed; 1,978 patients were eligible. Eligible patients were men aged 50 years and older who had no personal or family history of colorectal cancer or polyps, had not received colorectal cancer screening, and had at least one visit to the clinic during the study period. Health care providers in the intervention firm attended a workshop on colorectal cancer screening. Every 4 to 6 months, they attended quality improvement workshops where they received group screening rates, individualized confidential feedback, and training on improving communication with patients with limited literacy skills. Medical records were reviewed for colorectal cancer screening recommendations and completion. Literacy level was assessed in a subset of patients. RESULTS Colorectal cancer screening was recommended for 76.0% of patients in the intervention firm and for 69.4% of controls (P = .02). Screening tests were completed by 41.3% of patients in the intervention group versus 32.4% of controls (P = .003). Among patients with health literacy skills less than ninth grade, screening was completed by 55.7% of patients in the intervention group versus 30% of controls (P < .01). CONCLUSION A provider-directed intervention with feedback on individual and firm-specific screening rates significantly increased both recommendations and colorectal cancer screening completion rates among veterans.

Comparative Effectiveness of a Multifaceted Intervention to Improve Adherence to Annual Colorectal Cancer Screening in Community Health Centers: A Randomized Clinical Trial

IMPORTANCE Colorectal cancer (CRC) screening rates are lower among Latinos and people living in poverty. Fecal occult blood testing (FOBT) is one recommended screening modality that may overcome cost and access barriers. However, the ability of FOBT to reduce CRC mortality depends on high rates of adherence to annual screening. OBJECTIVE To determine whether a multifaceted intervention increases adherence to annual FOBT compared with usual care. DESIGN, SETTING, AND PARTICIPANTS Patient-level randomized controlled trial conducted in a network of community health centers. Included were 450 patients who had previously completed a home FOBT from March 2011 through February 2012 and had a negative test result: 72% of participants were women; 87% were Latino; 83% stated that Spanish was their preferred language; and 77% were uninsured. INTERVENTIONS Usual care at participating health centers included computerized reminders, standing orders for medical assistants to give patients home fecal immunochemical tests (FIT), and clinician feedback on CRC screening rates. The intervention group also received (1) a mailed reminder letter, a free FIT with low-literacy instructions, and a postage-paid return envelope; (2) an automated telephone and text message reminding them that they were due for screening and that a FIT was being mailed to them; (3) an automated telephone and text reminder 2 weeks later for those who did not return the FIT; and (4) personal telephone outreach by a CRC screening navigator after 3 months. MAIN OUTCOMES AND MEASURES Completion of FOBT within 6 months of the date the patient was due for annual screening. RESULTS Intervention patients were much more likely than those in usual care to complete FOBT (82.2% vs 37.3%; P < .001). Of the 185 intervention patients completing screening, 10.2% completed prior to their due date (intervention was not given), 39.6% within 2 weeks (after initial intervention), 24.0% within 2 to 13 weeks (after automated call/text reminder), and 8.4% between 13 and 26 weeks (after personal call). CONCLUSIONS AND RELEVANCE This intervention greatly increased adherence to annual CRC screening; most screenings were achieved without personal calls. It is possible to improve annual CRC screening for vulnerable populations with relatively low-cost strategies that are facilitated by health information technologies. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01453894.

Racial variation in the use of laparoscopic cholecystectomy in the Department of Veterans Affairs medical system.

BACKGROUND While studies have found racial differences in the rates of use of established invasive cardiac and cerebrovascular procedures, no study has evaluated racial variation in the rates of adoption of new surgical procedures. For patients undergoing laparoscopic cholecystectomy, the procedure represents a new and safe option that shortens the duration of postoperative hospitalization by almost one week. In this study, we evaluated whether, in the equal access Veterans Affairs (VA) medical system, the rate of adoption of this procedure and improvements in the duration of postoperative hospitalization differed between African-American and Caucasian patients. STUDY DESIGN Data were obtained from two sources-administrative claims files and prospectively compiled dinical data from medical records and patient interviews. In both data sets, frequency of use, length of stay, and outcomes for African-American and Caucasian patients undergoing minimally invasive and open gallbladder surgery were analyzed for the first four years of use of the procedure in the VA system (1992 to 1995). RESULTS Analyses based on claims files indicated that, after adjustment for potentially confounding variables, African-American patients who underwent cholecystectomy in VA medical centers were 25% less likely to undergo a minimally invasive cholecystectomy during the first 4 years of use of the new procedure (adjusted odds ratio, 0.74; 95% confidence interval, 0.66-0.83). Shortening of the average postoperative length of stay from 9 days or more in the prelaparoscopic era to less than 4.5 days for patients undergoing the laparoscopic procedure occurred in the first year for Caucasian patients, but did not occur until the fourth year for African-American patients (p<0.001). The overall difference in postoperative length of stay between African-American and Caucasian patients more than doubled from 1.7 days before introduction of laparoscopic cholecystectomy to 3.8 days in the fourth year. In comparison, analyses based on nurse-compiled clinical data indicated that, after adjustment for relevant clinical factors, racial variations in the rate of laparoscopic surgery were even larger (adjusted odds ratio for laparoscopic versus open cholecystectomy for African-American versus Caucasian veterans, 0.68; 95% confidence interval, 0.55-0.84). CONCLUSIONS Compared to Caucasian patients, African-American patients who underwent cholecystectomy in VA medical centers had an approximately 25% to 32% lower likelihood of undergoing minimally invasive cholecystectomy procedures. The differences in rates of adoption of laparoscopic surgery did not appear to be from more comorbid illnesses among African-American patients. African-American and Caucasian veterans may differ in their preference for new surgical procedures like laparoscopic cholecystectomy. Conversely, VA physicians may have been less likely to recommend laparoscopic cholecystectomies to African-American patients.

Process Evaluation in an Intervention Designed to Improve Rates of Colorectal Cancer Screening in a VA Medical Center

Colorectal cancer (CRC) is the third most common cancer in the United States. Although CRC screening is recommended for individuals 50 years and older, screening completion rates are low. This can be attributed to provider and patient barriers. We developed an intervention to improve provider recommendation and patient screening among noncompliant male veterans in a 2-year randomized controlled trial and examined the relationship between participation and study outcomes among patients and providers. Overall, providers who attended intervention sessions recommended CRC screening during 64% of patient visits and providers who did not attend any intervention sessions recommended screening during 54% of visits (p < .01). Patients of providers who attended intervention sessions also were more likely to be screened (42% versus 29%, p < .05). The patient intervention did not have the desired impact. The subgroup of patients in the patient intervention was not more likely to complete CRC screening.

Surgery and Adjuvant Chemotherapy Use Among Veterans With Colon Cancer: Insights From a California Study

PURPOSE US veterans have been shown to be a vulnerable population with high cancer rates, and cancer care quality in Veterans Affairs (VA) hospitals is the focus of a congressionally mandated review. We examined rates of surgery and chemotherapy use among veterans with colon cancer at VA and non-VA facilities in California to gain insight into factors associated with quality of cancer care. METHODS A retrospective cohort of incident colon cancer patients from the California Cancer Registry, who were > or = 66 years old and eligible to use VA and Medicare between 1999 and 2001, were observed for 6 months after diagnosis. RESULTS Among 601 veterans with colon cancer, 72% were initially diagnosed and treated in non-VA facilities. Among veterans with stage I to III cancer, those diagnosed and initially treated in VA facilities experienced similar colectomy rates as those at non-VA facilities. Stage III patients diagnosed and initially treated in VA versus non-VA facilities had similar odds of receiving adjuvant chemotherapy. In both settings, older patients had lower odds of receiving chemotherapy than their younger counterparts even when race and comorbidity were considered (age 76 to 85 years: odds ratio [OR] = 0.18; 95% CI, 0.07 to 0.46; age > or = 86 years: OR = 0.17; 95% CI, 0.04 to 0.73). CONCLUSION In California, older veterans with colon cancer used both VA and non-VA facilities for cancer treatment, and odds of receiving cancer-directed surgery and chemotherapy were similar in both systems. Among stage III patients, older age lowered odds of receiving adjuvant chemotherapy in both systems. Further studies should continue to explore potential health system effects on quality of colon cancer care across the United States.

Comparing the Performance of the S-TOFHLA and NVS Among and Between English and Spanish Speakers

Given the growing body of evidence demonstrating the significant implications of health literacy on a myriad of outcomes, researchers continue to incorporate health literacy metrics in studies. With this proliferation in measurement of health literacy in research, it has become increasingly important to understand how various health literacy tools perform in specific populations. Our objective was to compare the performance of two widely used tests, the Short Test of Functional Health Literacy in Adults (S-TOFHLA) and the Newest Vital Sign (NVS) among and between a sample of English and Spanish-speaking patients. Adults (N = 402) ages 50–75 years participating in a trial to promote colorectal cancer screening completed in-person interviews which included both measures of health literacy. In the full sample, the tests were moderately correlated (r = 0.69, p < .0001); however, there was a stronger correlation among those completing the test in Spanish (r = 0.83) as compared with English (r = 0.58, p < .0001). English speakers more often were categorized as having adequate literacy by the S-TOFHLA as compared with the NVS, whereas Spanish speakers scored consistently low on both instruments. These findings indicate that the categorization of participants into levels of literacy is likely to vary, depending on whether the NVS or S-TOFHLA is used for assessment, a factor which researchers should be aware of when selecting literacy assessments.