Stephen F. Rothemich

The Relative Importance of Patient-Reported Barriers to Colorectal Cancer Screening

BACKGROUND Colorectal cancer (CRC) screening rates are suboptimal. The most important barriers identified by patients are poorly understood. A comprehensive assessment of barriers to all recommended modalities is needed. METHODS In 2007, a questionnaire was mailed to 6100 patients, aged 50-75 years, from 12 family medicine practices in the Virginia Ambulatory Care Outcomes Research Network. People aged 65-75 years and African Americans were oversampled. Patients were asked to rate 19-21 barriers to each of four recommended tests. In 2008, responses were coded on a 5-point scale; higher scores reflected stronger barrier endorsement. RESULTS The response rate was 55% (n=3357). Approximately 40% of respondents were aged >/=65 years, 30% were African-American, and 73% were adherent to screening. A clinicians failure to suggest screening and not knowing testing was necessary received the highest mean scores as barriers. Financial concerns and misconceptions were also cited. Barrier scores differed depending on whether respondents were never screened, overdue for screening, or adherent to guidelines. The top five barriers for each modality included test-specific barriers (e.g., handling stool, bowel preparation), which often outranked generic barriers to screening. Not knowing testing was necessary was a top barrier for all tests but colonoscopy. CONCLUSIONS Although physician advice and awareness of the need for screening are important, barriers to screening are not homogenous across tests, and test-specific barriers warrant consideration in designing strategies to improve screening rates. Barrier scores differ by screening status, highlighting the need to address prior screening experience. Evidence that patients are more familiar with colonoscopy than with other modalities suggests an opportunity to improve screening rates by educating patients about alternative tests.

Putting It Together: Finding Success in Behavior Change Through Integration of Services

PURPOSE The purpose of this analysis and commentary was to explore the rationale for an integrated approach, within and outside the office, to help patients pursue healthy behaviors. METHODS We examined the role of integration, building on (1) patterns observed in a limited qualitative evaluation of 17 Prescription for Health projects, (2) several national policy initiatives, and (3) selected research literature on behavior change. RESULTS The interventions evaluated in Prescription for Health not only identified unhealthy behaviors and advised change, but also enabled patients to access information at home, use self-help methods, obtain intensive counseling, and receive follow-up. Few practices can replicate such a model with the limited staff and resources available in their offices. Comprehensive assistance can be offered to patients, however, by integrating what is feasible in the office with additional services available through the community and information media. CONCLUSIONS Blending diverse clinical and community services into a cohesive system requires an infrastructure that fosters integration. Such a system provides the comprehensive model on which the quality of both health promotion and chronic illness care depend. Integrating clinical and community services is only the first step toward the ideal of a citizen-centered approach, in which diverse sectors within the community—health care among them—work together to help citizens sustain healthy behaviors. The integration required to fulfill this ideal faces logistical challenges but may be the best way for a fragmented health care system to fully serve its patients.

Interactive Preventive Health Record to Enhance Delivery of Recommended Care: A Randomized Trial

PURPOSE Americans receive only one-half of recommended preventive services. Information technologies have been advocated to engage patients. We tested the effectiveness of an interactive preventive health record (IPHR) that links patients to their clinician’s record, explains information in lay language, displays tailored recommendations and educational resources, and generates reminders. METHODS This randomized controlled trial involved 8 primary care practices. Four thousand five hundred patients were randomly selected to receive a mailed invitation to use the IPHR or usual care. Outcomes were measured using patient surveys and electronic medical record data and included IPHR use and service delivery. Comparisons were made between invited and usual-care patients and between users and nonusers among those invited to use the IPHR. RESULTS At 4 and 16 months, 229 (10.2%) and 378 (16.8%) of invited patients used the IPHR. The proportion of patients up-to-date with all services increased between baseline and 16 months by 3.8% among intervention patients (from 11.4% to 15.2%, P <.001) and by 1.5% among control patients (from 11.1% to 12.6%, P = .07), a difference of 2.3% (P = .05). Greater increases were observed among patients who used the IPHR. At 16 months, 25.1% of users were up-to-date with all services, double the rate among nonusers. At 4 months, delivery of colorectal, breast, and cervical cancer screening increased by 19%, 15%, and 13%, respectively, among users. CONCLUSIONS Information systems that feature patient-centered functionality, such as the IPHR, have potential to increase preventive service delivery. Engaging more patients to use systems could have important public health benefits.

A Practice-Sponsored Web Site to Help Patients Pursue Healthy Behaviors: An ACORN Study

PURPOSE We tested whether patients are more likely to pursue healthy behaviors (eg, physical activity, smoking cessation) if referred to a tailored Web site that provides valuable information for behavior change. METHODS In a 9-month pre-post comparison with nonrandomized control practices, 6 family practices (4 intervention, 2 control) encouraged adults with unhealthy behaviors to visit the Web site. For patients from intervention practices, the Web site offered tailored health advice, a library of national and local resources, and printouts for clinicians. For patients from control practices, the Web site offered static information pages. Patient surveys assessed stage of change and health behaviors at baseline and follow-up (at 1 and 4 months), Web site use, and satisfaction. RESULTS During the 9 months, 932 patients (4% of adults attending the practice) visited the Web site, and 273 completed the questionnaires. More than 50% wanted physician assistance with health behaviors. Stage of change advanced and health behaviors improved in both intervention and control groups. Intervention patients reported greater net improvements at 1 month, although the differences approached significance only for physical activity and readiness to change dietary fat intake. Patients expressed satisfaction with the Web site but wished it provided more detailed information and greater interactivity with clinicians. CONCLUSIONS Clinicians face growing pressure to offer patients good information on health promotion and other health care topics. Referring patients to a well-designed Web site that offers access to the world’s best information is an appealing alternative to offering handouts or impromptu advice. Interactive Web sites can facilitate behavior change and can interface with electronic health records. Determining whether referral to an informative Web site improves health outcomes is a methodological challenge, but the larger question is whether information alone is sufficient to promote behavior change. Web sites are more likely to be effective as part of a suite of tools that incorporate personal assistance.

Engaging Primary Care Patients to Use a Patient-Centered Personal Health Record

PURPOSE Health care leaders encourage clinicians to offer portals that enable patients to access personal health records, but implementation has been a challenge. Although large integrated health systems have promoted use through costly advertising campaigns, other implementation methods are needed for small to medium-sized practices where most patients receive their care. METHODS We conducted a mixed methods assessment of a proactive implementation strategy for a patient portal (an interactive preventive health record [IPHR]) offered by 8 primary care practices. The practices implemented a series of learning collaboratives with practice champions and redesigned workflow to integrate portal use into care. Practice implementation strategies, portal use, and factors influencing use were assessed prospectively. RESULTS A proactive and customized implementation strategy designed by practices resulted in 25.6% of patients using the IPHR, with the rate increasing 1.0% per month over 31 months. Fully 23.5% of IPHR users signed up within 1 day of their office visit. Older patients and patients with comorbidities were more likely to use the IPHR, but blacks and Hispanics were less likely. Older age diminished as a factor after adjusting for comorbidities. Implementation by practice varied considerably (from 22.1% to 27.9%, P <.001) based on clinician characteristics and workflow innovations adopted by practices to enhance uptake. CONCLUSIONS By directly engaging patients to use a portal and supporting practices to integrate use into care, primary care practices can match or potentially surpass the usage rates achieved by large health systems.

Effect on cessation counseling of documenting smoking status as a routine vital sign: An ACORN study

PURPOSE Guidelines encourage primary care clinicians to document smoking status when obtaining patients’ blood pressure, temperature, and pulse rate (vital signs), but whether this practice promotes cessation counseling is unclear. We examined whether the vital sign intervention influences patient-reported frequency and intensity of tobacco cessation counseling. METHODS This study was a cluster-randomized, controlled trial conducted in the Virginia Ambulatory Care Outcomes Research Network (ACORN). At intervention practices, nurses and medical assistants were instructed to assess the tobacco use status of every adult patient and record it with the traditional vital signs. Control practices did not use any systematic tobacco screening or identification system. Outcomes were the proportion of smokers reporting clinician counseling of any kind and the frequency of 2 counseling subcomponents: simple quit advice and more intensive discussion. RESULTS A total of 6,729 adult patients (1,149 smokers) at 18 primary care practices completed exit questionnaires during a 6-month comparison period. Among 561 smokers at intervention practices, 61.9% reported receiving any counseling, compared with 53.4% of the 588 smokers at control practices, for a difference of 8.6% (P = .04). The effect was largely restricted to simple advice, which was reported by 59.9% of intervention patients and 51.5% of control patients (P=.04). There was no significant increase in more extensive discussion, with 32.5% and 29.3% of patients at intervention and control practices, respectively, reporting this type of counseling (P=.18). CONCLUSIONS The vital sign intervention promotes tobacco counseling at primary care practices through a modest increase in simple advice to quit. When implemented as a stand-alone intervention, it does not appear to increase intensive counseling.

Patient Costs As a Barrier to Intensive Health Behavior Counseling

BACKGROUND Although intensive health behavior counseling has been demonstrated to help patients lose weight and quit smoking, many payers offer limited coverage for such counseling. PURPOSE This mixed-methods case study examined how coverage affected utilization of an electronic linkage system (eLinkS) to help adult patients obtain intensive health behavior counseling, provided through a collaboration of primary care practices and community programs. METHODS Grant support enabled patients to obtain counseling at no cost, but funds were exhausted within 5 weeks as a result of an overwhelming response. To study the influence of cost as a barrier, referrals were resumed for an additional 3 weeks, but patients were required to pay for them. Use of eLinkS, level of clinician counseling and referrals, and patient interest in referrals were measured using electronic medical record data and patient and clinician interviews. RESULTS When counseling was free, approximately one in five patients with an unhealthy behavior and an eLinkS prompt was referred for intensive counseling. However, when patient charges were instituted, referrals decreased by 97% (from 21.8% to 0.7%, p<0.001); clinicians asked fewer patients about health behaviors (37% vs 29%, p<0.001); clinicians offered fewer patients referrals (29% vs 6%, p<0.001); and patients were less interested in accepting referrals (76% vs 14%, p<0.001). In interviews, patients and clinicians cited cost as a major barrier. CONCLUSIONS Coverage for intensive health behavior counseling is important to utilization, particularly for interventions that involve clinician-community partnerships. The potential public health benefits of such collaborations to reduce unhealthy behaviors justify the elimination of financial barriers (e.g., copayments) by payers.

THE PRIORITY IS SCREENING, NOT COLONOSCOPY

Like Neugut and Lebwohl,1 we welcome the recent successes in promoting colorectal cancer screening. We also agree that offering too many testing options can dampen enthusiasm for screening, but we disagree with their solution: to promote a “preferred” test. Setting aside the question of whether colonoscopy is the “best” test—Neugut and Lebwohl themselves acknowledge that only fecal occult blood testing (FOBT) has been proven to lower mortality rates2—promoting a single test is risky because patient preferences are heterogeneous. A sizable proportion of the 50% of the population the authors wish to reach will decline an invasive examination and bowel preparation for screening but will undergo FOBT (and undergo colonoscopy if the results are abnormal). A campaign that makes colorectal cancer screening synonymous with colonoscopy, as espoused by the authors, could potentially “turn off” those reluctant patients who might consider screening by other means. The revamped Web site of Twitter, a social networking and microblogging service utilizing instant messaging, SMS (short message service, usually mobile-to-mobile text messages), or a Web interface. Photograph by David Brabyn. Printed with permission of Corbis. Although we agree that presenting 7 options for screening is excessive, it seems reasonable to offer at least 2 alternatives—FOBT and colonoscopy—which exhibit comparable effectiveness in empirical and modeling studies.2,3 Having options is important not only to accommodate patient preferences and extend screening to people who are averse to colonoscopy but also for communities that cannot supply enough endoscopists4 or offer colonoscopy at an affordable cost but can provide FOBT. FOBT limits the volume of screening colonoscopies, lowering costs5 without compromising health benefits.3 Choosing between colonoscopy and FOBT need not overwhelm patients if clinicians succinctly explain the contrasts—in frequency, invasiveness, and logistics—and present both tests as excellent choices, with a decision to forego screening being the only bad choice. Although gastroenterologists understandably prefer colonoscopy and favor guidelines that invoke a hierarchy6 over those that emphasize choices,2 Neugut and Lebwohl offer little evidence that their approach improves screening rates. The increase in screening that they observed in New York City between 2003 and 2006 (from 40% to 60%) is not unlike the secular trend observed nationally. Between 2002 and 2006, rates for screening by lower endoscopy (approximately 80% involving colonoscopy7,8) increased from 45% to 56% in the United States9 (to 61% in New York State10). Clearly, the increase in New York City is only partly attributable to promoting colonoscopy. A controlled study would help clarify whether “its time for a colonoscopy” is a message that achieves better results than one emphasizing choices in colorectal cancer screening.