Melissa R. Partin

Validation of Screening Questions for Limited Health Literacy in a Large VA Outpatient Population

ObjectivesPrevious studies have shown that a single question may identify individuals with inadequate health literacy. We evaluated and compared the performance of 3 health literacy screening questions for detecting patients with inadequate or marginal health literacy in a large VA population.MethodsWe conducted in-person interviews among a random sample of patients from 4 VA medical centers that included 3 health literacy screening questions and 2 validated health literacy measures. Patients were classified as having inadequate, marginal, or adequate health literacy based on the Short Test of Functional Health Literacy in Adults (S-TOFHLA) and the Rapid Estimate of Adult Literacy in Medicine (REALM). We evaluated the ability of each of 3 questions to detect: 1) inadequate and the combination of “inadequate or marginal” health literacy based on the S-TOFHLA and 2) inadequate and the combination of “inadequate or marginal” health literacy based on the REALM.Measurements and Main ResultsOf 4,384 patients, 1,796 (41%) completed interviews. The prevalences of inadequate health literacy were 6.8% and 4.2%, based on the S-TOHFLA and REALM, respectively. Comparable prevalences for marginal health literacy were 7.4% and 17%, respectively. For detecting inadequate health literacy, “How confident are you filling out medical forms by yourself?” had the largest area under the Receiver Operating Characteristic Curve (AUROC) of 0.74 (95% CI: 0.69–0.79) and 0.84 (95% CI: 0.79–0.89) based on the S-TOFHLA and REALM, respectively. AUROCs were lower for detecting “inadequate or marginal” health literacy than for detecting inadequate health literacy for each of the 3 questions.ConclusionA single question may be useful for detecting patients with inadequate health literacy in a VA population.

Impact of Age and Comorbidity on Colorectal Cancer Screening Among Older Veterans

Context Guidelines increasingly state that screening for cancer should be targeted to people who will live long enough to benefit from it. Content The investigators studied receipt of colorectal cancer screening in 27068 screen-eligible VA patients 70 years or older. Only 47% of patients with no comorbidity (5-year mortality rate, 19%) were screened, whereas 41% with severe comorbidity (5-year mortality rate, 55%) were screened. Rates were somewhat lower for older men but varied only slightly by life expectancy. Caution Some tests may have been done for diagnosis rather than screening. Implication In this population of elderly men, screening did not target healthier patients. The Editors Colorectal cancer screening guidelines recommend screening older adults who have substantial life expectancies according to age and comorbid conditions (1). For example, the U.S. Preventive Services Task Force recommends routine screening until age 75 years, whereas the Veterans Health Administration, the American Cancer Society, and the American Geriatrics Society (25) recommend colorectal cancer screening for older adults unless they are unlikely to live 5 years or have significant comorbid conditions that would preclude treatment. Targeting screening to healthy persons who are likely to live at least 5 years is recommended because randomized trials of fecal occult blood testing (FOBT) suggest that a difference in colorectal cancer mortality between screened and unscreened persons does not become noticeable until at least 5 years after screening (68). Therefore, persons with a life expectancy of 5 years or less are not likely to benefit from screening but remain at risk for harms that may occur immediately, such as complications from procedures and the treatment of clinically unimportant disease (9, 10). However, it remains unclear whether screening is being targeted to healthy older persons with substantial life expectancies and avoided in older persons with significant comorbidity, for whom the risks of screening outweigh the benefits. Previous studies of associations among age, comorbidity, and receipt of cancer screening have found that age is a stronger determinant of screening than comorbidity. For example, whereas advancing age is consistently associated with lower screening rates, worsening comorbidity has had little effect on the use of screening mammography, Papanicolaou smears, or prostate-specific antigen screening (1113). Previous studies of the relationship between colorectal cancer screening and comorbidity have been limited by small sample size, short follow-up times, and focus on FOBT rather than all types of colorectal cancer screening tests (14, 15). In addition, previous Veterans Affairs (VA) studies have not measured colorectal cancer screening performed outside the VA health care system by means of Medicare (1517). Having a better understanding of how comorbidity and age affect overall screening use is particularly important for colorectal cancer screening because the tests and follow-up procedures are often more invasive than those for other types of cancer and may result in substantial harms, such as major bleeding events, colon perforation, or strokeespecially in elderly persons with limited life expectancies (9, 18, 19). To characterize the use of colorectal cancer screening across a prognostic spectrum of advancing age and comorbidity, we examined VA data and Medicare claims for patients 70 years of age or older who were seen at 4 geographically diverse VA facilities. Specifically, we determined 2-year screening incidence and 5-year mortality rate for subgroups of older patients without significant comorbidity for whom guidelines recommend screening, as well as for subgroups of older patients with severe comorbidity for whom most guidelines agree that the risks of screening outweigh the benefits. Methods Data Sources and Patients We identified a cohort of screen-eligible patients on 1 January 2001 and followed them for 2 years for the performance of colorectal cancer screening. We obtained data for this cohort study from National VA Data Systems, clinical data extracted from the electronic record system (Veterans Health Information Systems and Technology Architectures) of 4 VA medical centers (Minneapolis, Minnesota; Durham, North Carolina; Portland, Oregon; and West Los Angeles, California), and Medicare claims. National VA data included the National Patient Care Database (which captures all inpatient and outpatient claims within the VA), Fee Basis Files (which capture claims for non-VA services paid for by the VA), and the Vital Status File (which captures mortality data for veterans) (20). Clinical data extracted from the 4 VA centers included text entered by clinicians in response to computerized clinical reminders about colorectal cancer screening (21). We used linked Medicare claims from the VA Information Resource Center to capture services provided to our cohort outside the VA by Medicare (22). On the basis of these data sources, we identified a cohort of 60933 patients 70 years of age or older who had at least 1 outpatient visit within the VA health care system or Medicare between 1 January 2000 and 31 December 2000 (the period during which we measured comorbidity) and at least 1 outpatient visit at 1 of the 4 VA centers between 1 January 2001 and 31 December 2002 (the period during which we measured the performance of colorectal cancer screening) (Figure 1). We selected the 4 VA centers for geographic diversity. We excluded 11817 (19%) patients who were enrolled in Medicare managed care at any point from 1 January 2000 to 31 December 2002, because they lacked Medicare claims. In addition, patients had to be eligible for screening to be included in our cohort. Therefore, we used VA and Medicare inpatient and outpatient claims from the 8-year period before the start of 2001 (dating back to 1 October 1992 for VA claims and 1 January 1999 for Medicare claims) to exclude 11200 (18%) patients with a history of colorectal cancer, colitis, colorectal polyps, colectomy, or colostomy and 8153 (13%) patients who had any history of a colonoscopy or had had a sigmoidoscopy or barium enema within 5 years and were therefore not due for screening at the start of 2001. We also used claims from the 6 months before their index test to exclude 2695 (4%) of patients who had signs or symptoms that would justify the performance of a test for nonscreening purposes (Figure 1). This left a final screen-eligible cohort of 27068 patients on 1 January 2001. Figure 1. Study flow diagram. Eligibility criteria included having been seen in an outpatient clinic at 1 of 4 Veterans Affairs (VA) centers between 1 January 2001 and 31 December 2002, which indicated that the VA was at least partially responsible for medical care, but data on colorectal cancer screening were gathered during the entire 2-year screening interval from both national VA and Medicare claims. Additional eligibility criteria included having at least 1 outpatient visit between 1 January and 31 December 2000 to define comorbidity as of 1 January 2001. *Defined by searching VA and Medicare inpatient and outpatient claims before 1 January 2001, dating as far back as 1 October 1992 for VA claims and 1 January 1999 for Medicare claims. Data Collection and Measurement Outcome Variables We assessed receipt of colorectal cancer screening between 1 January 2001 and 31 December 2002 for our cohort across the VA health care system and Medicare, because many elderly veterans use more than 1 VA center and most are enrolled in Medicare (23). We identified colorectal cancer screening in National VA Data Systems and linked Medicare payment data (hospital outpatient and physician/supplier files) by using International Classification of Disease, Ninth Revision (ICD-9), codes; Current Procedural Terminology (CPT) codes; and Level II Healthcare Common Procedure Coding System (HCPCS) codes for FOBT (CPT codes 82270, 82273, and 82274 and HCPCS code G0107), colonoscopy (ICD-9 codes 45.22, 45.23, 45.25, 45.41, 45.42, and 45.43; CPT codes 44388 to 44394, 45355, and 45378 to 45385; and HCPCS codes G0105, G0121), sigmoidoscopy (ICD-9 codes 45.24, 48.22 to 48.24, 48.26, 48.35, and 48.36; CPT codes 45300, 45303, 45305, 45308, 45309, 45315, 45320, 45330 to 45334, and 45337 to 45339; and HCPCS code G0104), or barium enema (ICD-9 code 87.64; CPT codes 74270 and 74280; and HCPCS codes G0106, G0120, and G0122) (2427). We assigned patients to 1 of the 4 screening procedures on the basis of their first test during 2001 through 2002. We chose a 2-year screening period to allow sufficient time for screening tests to be scheduled and performed; this is also the screening interval used in randomized trials of FOBT (6, 7). We obtained vital status through 31 December 2005 from the VA Vital Status File to determine 5-year mortality rates. The VA Vital Status File is similar to the National Death Index in terms of accuracy and completeness (28). We used 5-year mortality rates descriptively to identify conditions associated with having a life expectancy less than 5 years (5-year mortality rate >50%). Predictor Variables We assigned patients to 1 of 3 categories on the basis of their age on 1 January 2001: 70 to 74 years, 75 to 79 years, or 80 years or older. We defined the burden of comorbidity by using the Deyo adaptation of the Charlson Comorbidity Index (2931), a summary measure of 19 chronic disease diagnoses from administrative data that are selected and weighted according to their association with mortality. We calculated CharlsonDeyo scores from VA and Medicare inpatient and outpatient claims during the 12 months before the start of 2001 (3234). We categorized patients as having no significant comorbidity if they had a CharlsonDeyo score of 0, average comorbidity if they had a CharlsonDeyo score of 1 to 3, and severe comorbidity if they had a CharlsonDeyo score of 4 or greater. We chose th

Randomized trial examining the effect of two prostate cancer screening educational interventions on patient knowledge, preferences, and behaviors

AbstractOBJECTIVE: To assess the effect of video and pamphlet interventions on patient prostate cancer (CaP) screening knowledge, decision-making participation, preferences, and behaviors. DESIGN: Randomized, controlled trial. SETTING: Four midwestern Veterans Affairs medical facilities. PATIENTS/PARTICIPANTS: One thousand, one hundred fifty-two male veterans age 50 and older with primary care appointments at participating facilities were randomized and 893 completed follow-up. INTERVENTIONS: Patients were randomized to mailed pamphlet, mailed video, or usual care/control. MEASUREMENTS AND MAIN RESULTS: Outcomes assessed by phone survey 2 weeks postintervention included a 10-item knowledge index; correct responses to questions on CaP natural history, treatment efficacy, the prostate-specific antigen (PSA)’s predictive value, and expert disagreement about the PSA; whether screening was discussed with provider; screening preferences; and PSA testing rates.Mean knowledge index scores were higher for video (7.44; P=.001) and pamphlet (7.26; P=.03) subjects versus controls (6.90). Video and pamphlet subjects reported significantly higher percentages of correct responses relative to controls to questions on CaP natural history (63%, 63%, and 54%, respectively); treatment efficacy (19%, 20%, and 5%), and expert disagreement (28%, 19%, and 8%), but not PSA accuracy (28%, 22%, and 22%). Pamphlet subjects were more likely than controls to discuss screening with their provider (41% vs 32%; P=.03) but video subjects were not (35%; P=.33). Video and pamphlet subjects were less likely to intend to have a PSA, relative to controls (63%, 65%, and 74%, respectively). PSA testing rates did not differ significantly across groups. CONCLUSIONS: Mailed interventions enhance patient knowledge and self-reported participation in decision making, and alter screening preferences. The pamphlet and video interventions evaluated are comparable in effectiveness. The lower-cost pamphlet approach is an attractive option for clinics with limited resources.

Gender differences in colorectal cancer screening barriers and information needs

Context  Several prior studies have found that women are less likely to be screened for colorectal cancer (CRC) than men. While the source of this screening differential is unknown, recent studies suggest gender differences in barriers to screening might explain the disparity.

Validation of Self-Reported Colorectal Cancer Screening Behavior from a Mixed-Mode Survey of Veterans

Objective: The aim of the study was to validate self-reported colorectal cancer (CRC) screening using the National Cancer Institute Colorectal Cancer Screening questionnaire. Materials and Methods: 890 patients, ages 50 to 75 years, from the Minneapolis Veterans Affairs (VA) Medical Center were surveyed by mail. Phone administration was attempted with mail nonresponders. VA and non-VA records were combined for the reference standard. Sensitivity, specificity, concordance, and report-to-records ratio (R2R) were estimated for overall and test-specific CRC adherence among respondents providing complete medical records. Secondary analyses examined variation in estimates by patient characteristics, treatment of missing and uncertain responses, and whether a strict or liberal time interval was used for assessing concordance. Results: Complete medical records were available for 345 of the 686 survey responders. For overall adherence, sensitivity was 0.98, specificity was 0.59, concordance was 0.88, and R2R was 1.14. Sensitivity was 0.82 for fecal occult blood test (FOBT), 0.75 for sigmoidoscopy, 0.97 for colonoscopy, and 0.63 for double-contrast barium enema (DCBE). Specificity was 0.89 for FOBT, 0.76 for sigmoidoscopy, 0.72 for colonoscopy, and 0.85 for DCBE. Concordance was >0.80 for all tests other than sigmoidoscopy (0.76). R2R was 1.31 for FOBT, 1.33 for sigmoidoscopy, 1.42 for colonoscopy, and 6.13 for DCBE. The R2R was lower for a combined sigmoidoscopy and colonoscopy measure. Overreporting was more pronounced for older, less-educated individuals with no family history of CRC. Sensitivity and R2R improved using a liberal interval and treating uncertain responses as nonadherent (versus missing), but differences were not statistically significant. Conclusions: Self-reported CRC screening validity is generally acceptable and robust across definitional decisions, but varies by screening test and patient characteristics. (Cancer Epidemiol Biomarkers Prev 2008;17(4):768–76)

The Effect of Perceived Racial Discrimination on Bodily Pain among Older African American Men

OBJECTIVES We examined the extent to which experiences of racial discrimination are associated with bodily pain reported by African American men. METHODS The study sample consisted of 393 African American male veterans who responded to a national survey of patients aged 50-75 who received care from the Veterans Health Administration (VHA). Veterans were surveyed by mail, with a telephone follow-up. The response rate for African Americans in the sample was 60.5%. Pain (assessed using the bodily pain subscale of the 36-item short-form health survey), experiences of discrimination, employment, education, and income were obtained through the survey. Age, race, and mental health comorbidities were obtained from VA administrative data. Multiple regression analysis adjusting for item non-response (via imputation) and unit non-response (via propensity scores and weighting) was used to assess the association between racial discrimination and likelihood of experiencing moderate or severe pain over the past 4 weeks. RESULTS Experiences of racial discrimination were associated with greater bodily pain (beta = -0.25, P < 0.0001), even after controlling for socioeconomic and health-related characteristics. CONCLUSION Perceived racial discrimination was associated with greater pain among a sample of older African American male patients in the VA. Additional research is needed to replicate this finding among other populations of African Americans.

Unintended Consequences of Implementing a National Performance Measurement System into Local Practice

ABSTRACTBACKGROUNDAlthough benefits of performance measurement (PM) systems have been well documented, there is little research on negative unintended consequences of performance measurement systems in primary care. To optimize PM systems, a better understanding is needed of the types of negative unintended consequences that occur and of their causal antecedents.OBJECTIVES(1) Identify unintended negative consequences of PM systems for patients. (2) Develop a conceptual framework of hypothesized relationships between PM systems, facility-level variables (local implementation strategies, primary care staff attitudes and behaviors), and unintended negative effects on patients.DESIGN, PARTICIPANTS, APPROACHQualitative study design using dissimilar cases sampling. A series of 59 in-person individual semi-structured interviews at four Veterans Health Administration (VHA) facilities was conducted between February and July 2009. Participants included members of primary care staff and facility leaders. Sites were selected to assure variability in the number of veterans served and facility scores on national VHA performance measures. Interviews were recorded, transcribed and content coded to identify thematic categories and relationships.RESULTSParticipants noted both positive effects and negative unintended consequences of PM. We report three negative unintended consequences for patients. Performance measurement can (1) lead to inappropriate clinical care, (2) decrease provider focus on patient concerns and patient service, and (3) compromise patient education and autonomy. We also illustrate examples of negative consequences on primary care team dynamics. In many instances these problems originate from local implementation strategies developed in response to national PM definitions and policies.CONCLUSIONSFacility-level strategies undertaken to implement national PM systems may result in inappropriate clinical care, can distract providers from patient concerns, and may have a negative effect on patient education and autonomy. Further research is needed to ascertain how features of centralized PM systems influence whether measures are translated locally by facilities into more or less patient-centered policies and processes.

Measuring patient knowledge of the risks and benefits of prostate cancer screening

This manuscript describes the development and validation of measures assessing patient knowledge about the risks and benefits of prostate cancer (CaP) screening. The measures described include a 10-item knowledge index and four single-item measures, used in previous studies, that assess knowledge of: CaP natural history and treatment efficacy, expert disagreement over the value of CaP screening, and the accuracy of the prostate specific antigen (PSA) test for CaP. We assessed the validity and reliability of these measures on a sample of 1152 male veteran patients age 50 and older. All knowledge index items had acceptable levels of discrimination, difficulty, and reliability. The index demonstrated strong evidence for construct and criterion validity. Much weaker validity evidence was found for the four single-item knowledge questions. The 10-item index developed in this study provides a valid and reliable tool for assessing patient knowledge of the risks and benefits of CaP screening.

Menthol Cigarettes and Smoking Cessation During an Aided Quit Attempt

Menthol may make cigarettes more addictive and rates of menthol cigarette smoking are disproportionately higher among Black. However, few studies have examined the association between menthol cigarette smoking and cessation, and the studies to date have produced conflicting findings. The present study examines the effect of menthol cigarette smoking on cessation among a multi-ethnic sample of smokers making a pharmacotherapy-aided quit attempt. We hypothesized that menthol cigarette smoking would be associated with lower smoking abstinence rates and conducted a secondary analysis of data from a multi-site randomized controlled trial of an intervention designed to facilitate repeat tobacco cessation treatment (N = 1,343). The intervention consisted of a patient phone call and a computerized provider prompt. The primary outcome for this analysis was 7-day point prevalence smoking abstinence. The average age of the sample was 56 years old. Overall, 25% of the sample smoked menthol cigarettes: 19% of Whites, 62% of Blacks, and 25% of other ethnicity (p<.001). We observed no significant effects for menthol cigarette smoking or ethnicity on smoking abstinence rates. In conclusion, combined with findings from previous research, this study suggests that smoking menthol cigarettes does not decrease smoking cessation among older smokers during a quit attempt aided with pharmacotherapy.

Variation in Estimates of Limited Health Literacy by Assessment Instruments and Non-Response Bias

ObjectivesThis paper compares estimates of poor health literacy using two widely used assessment tools and assesses the effect of non-response on these estimates.Study Design and SettingA total of 4,868 veterans receiving care at four VA medical facilities between 2004 and 2005 were stratified by age and facility and randomly selected for recruitment. Interviewers collected demographic information and conducted assessments of health literacy (both REALM and S-TOFHLA) from 1,796 participants. Prevalence estimates for each assessment were computed. Non-respondents received a brief proxy questionnaire with demographic and self-report literacy questions to assess non-response bias. Available administrative data for non-participants were also used to assess non-response bias.ResultsAmong the 1,796 patients assessed using the S-TOFHLA, 8% had inadequate and 7% had marginal skills. For the REALM, 4% were categorized with 6th grade skills and 17% with 7–8th grade skills. Adjusting for non-response bias increased the S-TOFHLA prevalence estimates for inadequate and marginal skills to 9.3% and 11.8%, respectively, and the REALM estimates for ≤6th and 7–8th grade skills to 5.4% and 33.8%, respectively.ConclusionsEstimates of poor health literacy varied by the assessment used, especially after adjusting for non-response bias. Researchers and clinicians should consider the possible limitations of each assessment when considering the most suitable tool for their purposes.