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The American Journal of Managed Care April 2013
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More Comprehensive Discussion of CRC Screening Associated With Higher Screening
David M. Mosen, PhD, MPH; Adrianne C. Feldstein, MD, MS; Nancy A. Perrin, PhD; A. Gabriela Rosales, MS; David H. Smith, RPh, PhD; Elizabeth G. Liles, MD; Jennifer L. Schneider, MPH; Ronald E. Myers, PhD; and Jennifer Elston-Lafata, PhD
Health Plan Innovations in Delivery System Reforms
Karen Ignagni
Prescription Opioid Abuse: Challenges and Opportunities for Payers
Nathaniel P. Katz, MD, MS; Howard Birnbaum, PhD; Michael J. Brennan, MD; John D. Freedman, MD; Gary P. Gilmore, RPh; Dennis Jay, BS; George A. Kenna, PhD, RPh; Bertha K. Madras, PhD; Lisa McElhaney, BS; Roger D. Weiss, MD; and Alan G. White, PhD
Effects of Coverage Gap Reform on Adherence to Diabetes Medications
Feng Zeng, PhD; Bimal V. Patel, PharmD, MS; and Louis Brunetti, MD
Primary Nonadherence to Statin Therapy: Patients' Perceptions
Teresa N. Harrison, SM; Stephen F. Derose, MD, MS; T. Craig Cheetham, PharmD, MS; Vicki Chiu, MS; Southida S. Vansomphone, PharmD; Kelley Green, RN, PhD; Kaan Tunceli, PhD; Ronald D. Scott, MD; Elizabeth Marrett, MPH; and Kristi Reynolds, PhD, MPH
Trends in Hospital-Based Childbirth Care: The Role of Health Insurance
Katy B. Kozhimannil, PhD, MPA; Tetyana P. Shippee, PhD; Olusola Adegoke, MPH, MBBS; and Beth A. Virnig, PhD, MPH
Disease Management Programs: Barriers and Benefits
Racheli Magnezi, MBA, PhD; Galit Kaufman, RN, MA; Arnona Ziv, MBA; Ofra Kalter-Leibovici, MD; and Haim Reuveni, MD
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James D. Ralston, MD, MPH; Michael J. Silverberg, PhD, MPH; Louis Grothaus, MA; Wendy A. Leyden, MPH; Tyler Ross, MA; Christine Stewart, PhD; Steven Carzasty, MSW; Michael Horberg, MD, MAS; and Sheryl L. Catz, PhD
Retail Clinic Utilization Associated With Lower Total Cost of Care
Andrew Sussman, MD; Lisette Dunham, MSPH; Kristen Snower, MBA; Min Hu, MPH; Olga S. Matlin, PhD; William H. Shrank, MD; Niteesh K. Choudhry, MD, PhD; and Troyen Brennan, MD

More Comprehensive Discussion of CRC Screening Associated With Higher Screening

David M. Mosen, PhD, MPH; Adrianne C. Feldstein, MD, MS; Nancy A. Perrin, PhD; A. Gabriela Rosales, MS; David H. Smith, RPh, PhD; Elizabeth G. Liles, MD; Jennifer L. Schneider, MPH; Ronald E. Myers, PhD; and Jennifer Elston-Lafata, PhD
More comprehensive discussion of colorectal screening by primary care physicians was associated with higher screening rates among adults aged 51 to 80 years who were overdue for screening.
Objectives: Examine association of comprehensiveness of colorectal cancer (CRC) screening discussion by primary care physicians (PCPs) with completion of CRC screening.

Study Design: Observational study in Kaiser Permanente Northwest, a group-model health maintenance organization.

Methods: A total of 883 participants overdue for CRC screening received an automated telephone call (ATC) between April and June 2009 encouraging CRC screening. Between January and March 2010, participants completed a survey on PCPs’ discussion of CRC screening and patient beliefs regarding screening. Primary outcome measure: receipt of CRC screening (assessed by electronic medical record [EMR], 9 months after ATC). Primary independent variable: comprehensiveness of CRC screening discussion by PCPs (7-item scale). Secondary independent variables: perceived benefits of screening (4-item scale assessing respondents’ agreement with benefits of timely screening) and primary care utilization (EMR; 9 months after ATC). The independent association of variables with CRC screening was assessed with logistic regression.

Results: Average scores for comprehensiveness of CRC discussion and perceived benefits were 0.4 (range 0-1) and 4.0 (range 1-5), respectively. A total of 28.2% (n = 249) completed screening, 84% of whom had survey assessments after their screening date. Of screeners, 95.2% completed the fecal immunochemical test. More comprehensive discussion of CRC screening was associated with increased screening (odds ratio [OR] = 1.51, 95% confidence interval [CI] = 1.03-2.21). Higher perceived benefits (OR = 1.46, 95% CI = 1.13-1.90) and 1 or more PCP visits (OR = 5.82, 95% CI = 3.87-8.74) were also associated with increased screening.

Conclusions: More comprehensive discussion of CRC screening was independently associated with increased CRC screening. Primary care utilization was even more strongly associated with CRC screening, irrespective of discussion of CRC screening.

Am J Manag Care. 2013;19(4):265-271
  •  More comprehensive discussion of CRC screening by PCPs was associated with higher screening rates among adults aged 51 to 80 years who were overdue for screening.
  •  Higher perceived benefits of CRC screening by patients was also associated with increased CRC screening.
  •  1 or more PCP visits was strongly associated with increased CRC screening, irrespective of discussion of CRC screening.
Colorectal cancer (CRC) is the third-most common cancer and the second-leading cause of cancer-related death in the United States.1 Recent estimates suggest that CRC will be newly diagnosed in about 112,340 people annually, resulting in over 52,180 deaths per year.2 Total direct costs associated with treating CRC are $17 billion annually, with 9.8 million work days lost annually to hospitalization for colon cancer.2

The early detection of high-risk lesions, or CRC itself, through appropriate screening is associated with decreased incidence of and mortality from CRC.3-5 The US Preventive Services Task Force recommends that men and women of average risk begin screening for CRC starting at age 50 years,6 and specialty care guidelines provide recommendations for higher-risk groups.7 Currently, recommended CRC screening modalities for average-risk patients include annual fecal occult blood testing (FOBT), colonoscopy every 10 years, or flexible sigmoidoscopy every 5 years, with or without interval FOBT.6 In addition, as a result of improved test performance and usability, in 2008 multiple professional societies endorsed the use of 4 types of fecal immunochemical tests (FITs) for CRC screening to replace FOBT.8,9

Despite the proven benefits of CRC screening, screening rates remain suboptimal. Although more than half of adults 50 years and older in the United States have ever received a CRC screening test, less than half receive screening tests at recommended intervals.10-17

While demographics (age, gender)12,18 and specific health-system characteristics are associated with receipt of CRC screening (having usual sources of care,12 access to endoscopy services,19 and assistance with scheduling of colonoscopy),20 less is known about how providerpatient interactions and comprehensiveness of CRC discussion by primary care physicians (PCPs) influence CRC screening. Previous studies indicate that physician recommendation for screening12,21,22 and good provider communication skills23 may increase CRC screening. However, less is known about how the comprehensiveness of discussion by PCPs about testing options, screening intervals, and potential test complications may influence actual CRC screening. Study of the association of the comprehensiveness of CRC discussion by PCPs with receipt of CRC screening can inform the development of quality-improvement interventions.

The primary objective of this study was to determine the independent association of comprehensiveness of CRC screening discussion by PCPs, as reported by patients, with receipt of CRC screening.


The protocol for this study was approved by the institutional review board within the study health maintenance organization (HMO).

Study Site, Survey, and Electronic Data Sources

The study was conducted at Kaiser Permanente Northwest (KPNW), a not-for-profit HMO with about 485,000 members in southwest Washington and the Portland, Oregon, metro area. The members’ demographic characteristics (age, gender, race/ethnicity) are similar to those of the area population.24 KPNW regional electronic databases provided data on patient membership, demographics, primary care assignment, clinical data (including weight and height, laboratory results, and other healthcare utilization, including CRC screening), and clinician data. These data capture over 95% of all medical care and pharmacy services members receive, and data are linked through each member’s health record number.

Patient Selection

We included HMO members aged 50 to 80 years who were at average risk for developing CRC, were overdue for CRC screening, and received an automated telephone call as part of a CRC screening-outreach program between March and June 2009.25 The specifics of the automated call program, including the definition of “average risk,” have been described previously.25 Essentially, the average-risk population includes those who are overdue for CRC screening and do not meet any of the following

criteria: (1) active colon cancer/risk factors that would indicate need for non-routine screening, (2) ever diagnosed with adenomatous polyps or human immunodeficiency virus/acquired immunodeficiency syndrome, (3) referred for colonoscopy or sigmoidoscopy in previous 3 months, or (4) receipt of plavix or warfarin medications in previous 4 months that may increase risk of false-positive FIT. The brief automated telephone calls (ATCs) included information about the benefits of CRC screening, encouraged FOBT as a relatively simple and lowrisk method of screening, and allowed patients to request an FOBT by pushing a number on their telephone. The date of the telephone call was defined as the intervention index date.

Of the population receiving automated telephone calls, a random sample of 2000 adults were mailed a survey in January 2010. We chose to begin survey outreach efforts in January 2010 in order to have the most time for those efforts, while still ensuring that sufficient time elapsed (6-9 months) for patients who received ATCs between March and June 2009 to complete screening.

The process flow of the survey administration process is described in the Figure.25 We sent initial surveys to study respondents on January 15, 2010. Next, we sent a reminder postcard to non-responders 2 weeks after the initial mailing. Finally, we mailed the survey a second time to non-responders about 3 weeks after the reminder postcard. Survey enrollment was completed by March 31, 2010. Of the whole population, 1816 (90.8%) were contacted. A total of 184 participants were not contacted due to incorrect addresses. Of those contacted, 883 completed the survey, for a response rate of 48.6% (883/1816). Compared with non-respondents, respondents were more likely to be white (respondents = 95.3% vs non-respondents = 87.5%, P <.0001), female (respondents = 58.3% vs non-respondents = 48.4%, P <.0001), and taking more medications (respondents [mean ± standard deviation (SD)] = [3.1 ± 3.8]). Responders and non-responders did not differ in age or length of health plan membership.

Patient Survey Design and Measures

This survey was designed to better understand the barriers and facilitators that patients encountered in their efforts to complete CRC screening. We focused on 2 patient-reported domains: (1) patients’ perceptions of clinician-patient counseling, such as comprehensiveness of CRC screening discussion by the PCP, and (2) patient beliefs; namely, perceived benefits of CRC screening. Comprehensiveness of CRC discussion was the primary independent variable, while primary care utilization and perceived benefits of CRC screening were the secondary independent variables.

Comprehensiveness of CRC Screening Discussion, Based on Patient Self-Report

Comprehensiveness of CRC screening discussion. These items were based on previous work from Braddock and colleagues26,27 that assessed levels of informed decision making occurring during patient-provider communications regarding CRC screening. Informed decision making, a means for facilitating patient participation in decision making, includes (1) providing relevant information about the clinical situation, alternatives, and risks and benefits; (2) assessing the patient’s understanding; and (3) giving the patient a clear opportunity to voice a preference.26,27 Seven yes/no items measured the content of patients’ discussions with their PCPs. We asked patients whether their PCPs did each of the following at any time in the 2 years prior to survey: (1) explained benefits of CRC screening, (2) discussed how often each screening test should be done, (3) provided information on how to do various tests, (4) explained the accuracy of each screening test, (5) explained potential test complications from screening tests, (6) asked if the patient understood or had any questions about CRC screening, and (7) asked if the patient had the information he or she wanted about CRC screening. These 7 items had high internal consistency (Cronbach’s alpha = 0.92). To calculate an average score, each of the 7 items was summed together (0.0 = no, 1.0 = yes) and divided by 7. A score of 1 indicates that patients answered “yes” to all 7 questions, while a score of 0 indicates a “no” answer to all 7 questions. Only the responses of patients who answered all 7 questions were included in the variable describing this scale.

Perceived Benefits of CRC Screening, Based on Patient Self-Report

Perceived benefits scale. Four items measured perceived benefits of CRC screening, scored on a 5-point Likert scale (1 = strongly disagree, 5 = strongly agree). Similar to the scale for comprehensiveness of CRC discussion, the perceived-benefits scale also had good internal consistency (Cronbach’s alpha = 0.80). To calculate an average score, each of the 4 items was summed together (1 = strongly disagree, 5 = strongly agree) and divided by 4. A score of 5 indicates that the respondent answered “strongly agree” to all 4 questions, and a score of 1 indicates an answer of “strongly disagree” to all 4 questions. Only the responses of patients who answered all 4 questions were included in the variable describing this scale. These questions were adapted from Myers and colleagues28-30 and measured general agreement with the following statements: (1) CRC screening is necessary even if no family history exists, (2) getting screening for CRC can protect health, (3) when colon polyps are found and removed, CRC can be prevented, and (4) when CRC is found early, it can be cured. The rationale for selecting perceived benefits is that beliefs about colon cancer have been identified in the literature as an important characteristic associated with CRC screening.28-30

Measures Identified From the EMR

All patients were due for screening at the time of the ATC; the primary outcome measure was whether the patient completed CRC screening in the 9 months following the ATC. CRC screening included any of the following: 1 sample FIT, receipt of colonoscopy, and receipt of flexible sigmoidoscopy. The distribution of first completed CRC screening test for this study population was FIT (95.2%), colonoscopy (2.8%), and sigmoidoscopy (2.0%).

We identified patient age in relation to the intervention index date, and we identified gender from member eligibility files. We also determined length of KPNW membership. Individual racial categories were obtained from electronic databases for 267 (30.4%) participants, and missing data were imputed using the census tract block corresponding to each subject’s mailing address. Patient race was categorized as white or non-white (African American, Pacific Islander, Asian, and Native American). In addition, as a measure intended to reflect disease burden,31 we determined the mean number (± SD) of unique generic drugs dispensed within the 6 months prior to index date for each participant. We also determined whether survey respondents had any primary care visits (internal medicine, family practice; >1 visits vs none) in the 9 months after the intervention index date.

Statistical Methods

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