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The American Journal of Managed Care September 2013
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Referring Patients for Telephone Counseling to Promote Colorectal Cancer Screening
Roger Luckmann, MD, MPH; Mary E. Costanza, MD; Milagros Rosal, PhD; Mary Jo White, MS, MPH; and Caroline Cranos, MPH
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Referring Patients for Telephone Counseling to Promote Colorectal Cancer Screening

Roger Luckmann, MD, MPH; Mary E. Costanza, MD; Milagros Rosal, PhD; Mary Jo White, MS, MPH; and Caroline Cranos, MPH
In this pilot study, primary care providers refer patients to a telephone counselor who provides education about colorectal cancer screening and performs motivational interviewing as needed to promote screening.
Of the 362 patients recommended for counseling, 180 (49.7%) accepted a counseling referral. Referral acceptance varied significantly by site, age, and preferred language (Table 1). A total of 140 of the 180 patients (77.8%) accepting referral were reached by phone and underwent initial screening and staging. Of 104 patients who remained eligible and scheduled an appointment for counseling, 67 (64.4%) were ultimately reached and were willing to undergo counseling. Out of 62 patients who refused counseling at the screening or the counseling call or who had a counseling appointment and could not be reached, 42 had provided information on their stages of readiness during the screening call: 45.2% were planning, 28.6% were undecided, 16.7% decided no, and 9.5% were unengaged.

Counseling Outcomes

At the beginning of the counseling call, 36 (54.5%) subjects were planning on CRC screening (19.7% colonoscopy, 3.0% FOBT, 19.7% undecided on the specific test, 12.1% other test—sigmoidoscopy, barium enema, or virtual colonoscopy). Seven (10.6%) were unengaged, 17 (25.8%) were undecided, and 6 (9.1%) were decided against screening. This distribution of stages among counseled patients was similar to the stage distribution among the 42 patients staged at screening but not counseled (P = .56). By the end of counseling, 62 (93.9%) of 66 counseled subjects with complete staging information were planning on getting a screening test (75.8% colonoscopy, 22.6% FOBT, 1.6% other test), and of the 4 who were not planning, all were undecided (Table 2). Thirty-eight of 40 patients who moved to planning during counseling (95.0%) did so following the educational module. Most calls lasted 10 to 20 minutes.

Patient Satisfaction

Twenty-three patients who completed counseling participated in a telephone interview to assess their responses to the mailed booklet and the counseling call. All agreed that the call was valuable, gave the counselor high ratings, and reported that the booklet was satisfactory. A few subjects identified questions about CRC and screening that they felt were not addressed by the booklet and call.

Colonoscopy Completion

For those planning any test at the end of the call (n = 62), the colonoscopy completion rate was 53.2% (95% CI: 40.1-60.0), and for those specifically planning a colonoscopy, 68.1% (95% CI: 52.9-80.9). Of the 4 patients undecided after the call, only 1 received a colonoscopy (25%, 95% CI: 6.3-80.6). Of 6 counseled patients initially decided against screening, none received a  colonoscopy even though 3 were planning a colonoscopy by the end of counseling. Those completing counseling had the highest colonoscopy completion rate (50.7%), more than twice the rates for 2 other groups (those refusing referral and those referred but not counseled, P = .0001) (Table 3). Among patients who were staged at the screening call (n = 107), colonoscopycompletion rates were higher within each stage for those who completed counseling and had complete staging information (n = 66): planning, 69.4% versus 38.9% (P = .031), 30.0% versus 8.7% for all other stages (P = .089). In a logistic regression model with the outcome of colonoscopy completion and including age, gender, and health center, outcomes for those completing counseling and those accepting a referral and not completing counseling were compared with the outcome for those refusing the referral. Patients who completed counseling were more than 4 times as likely to complete colonoscopy as those refusing referral (adjusted odds ratio [OR] 4.35, 95% CI: 2.41-7.86). Patients not completing counseling but who did accept a referral for counseling from the PCP were more than twice as likely to complete colonoscopy as those refusing referral (adjusted OR 2.38, 95% CI: 1.23-4.61). In the model health center, gender and age were all not statistically significant.

DISCUSSION

We aimed to assess the feasibility and acceptability to patients and PCPs of a CRC telephone counseling intervention initiated by a PCP referral in a face-to-face patient encounter. We found that during some routine clinical encounters PCPs were willing and able to identify and refer many patients they thought could benefit from counseling on CRC screening, but that only about half of the patients asked accepted a referral. Of the 180 patients accepting referral only about one-third could be reached for  counseling and accepted the call, suggesting that referral as delivered in this intervention was not a very powerful motivator for patients to accept and comply with telephone counseling. We did not provide any training to PCPs on how to motivate patients to accept a referral. It is possible that training PCPs to offer a brief motivational intervention could increase referral acceptance and completion. The rate of counseling could likely have been increased if counseling were performed at the initial patient telephone contact. However, we elected to separate the screening call from a subsequent counseling call that we scheduled at a time convenient for patients so they could review the print materials and set aside uninterrupted time for the counseling. Even without the expected increase in acceptance and counseling rates that we believe would occur with the modifications of the intervention described above, we believe the study demonstrates that this type of intervention is at least feasible in primary care practice given the willingness of all PCPs and some patients to engage in the intervention as designed.

Because this was a single-arm pilot study we cannot exclude selection bias as a predominant explanation for differences in screening rates across subgroups or between screening rates in this study compared with rates in other studies. The finding that patients completing counseling and those accepting referral but not competing counseling were about 4.35 and 2.38 times more likely to have a colonoscopy than those refusing counseling is consistent with an intervention effect, but could also be entirely due to self-selections of patients who would have received a colonoscopy without the intervention. Nevertheless, we believe the outcomes we found suggest that telephone counseling warrants future study. The change in stage of readiness for screening of counseled patients was significant. Nearly half (27 out of 67) of those counseled were not planning on CRC screening at the beginning of the call. But by the end all were planning except 4 who were undecided. Since most patients whochanged stage did so after the educational module, educational intervention alone may be as effective as education plus motivational interviewing.

The overall colonoscopy rate over 6 to 9 months in the referred group (24.6%) compares favorably with the rates reported in randomized trials of telephone counseling. In 4 studies the rates of colonoscopy over about 6 to 12 months ranged from about 12 to 27%.11-12,15,16 Ling and colleagues reported that 53.8% of patients in their intensive intervention group (a letter, followed by tailored telephone counseling and motivational interviewing) received a colonoscopy or sigmoidoscopy over a 12-month period.13 In a randomized trial, Costanza and colleagues evaluated a telephone counseling intervention in patients receiving care from the same group practice that providers in this study belonged to. The rate of colonoscopy in both the intervention and control group was only 12%. In the 4 other studies cited above the colonoscopy rates were significantly higher in the intervention than in the control group. While we cannot attribute the screening rate we found in the referred group to counseling, the fact that the rate is higher than the control group rates in similar studies is reason to consider further study of our intervention.

Limitations

This was a pilot study without randomized controls, so intervention effectiveness compared with usual care could not be determined. Because we sampled only patients at clinical encounters, the sample was not representative of all patients due for CRC screening, but of those who have at least 1 clinic visit per year. We did not assess fidelity of the counseling as delivered to the protocol, so we are unable to attribute possible effects of counseling definitively to the protocol.

CONCLUSION

Prompting PCPs to recommend CRC screening to eligible patients and to refer selected patients to a telephone education and counseling service that includes facilitated completion of a CRC screening test is feasible and acceptable to PCPs and to some patients. Our findings suggest several ways to improve the referral process and support further evaluation of the intervention in studies that compare it with usual care and with other interventions.

Author Affiliations: From the University of Massachusetts Medical School (RL, MEC, MR, MJW, CC), Worcester, MA.

Funding Source: This research was funded by grant CA 107197 from the National Cancer Institute.

Author Disclosures: The authors (RL, MEC, MR, MJW, CC) report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (RL, MEC, MR); acquisition of data (RL, CC); analysis and interpretation of data (RL, MEC, MR, MJW, CC); drafting of the manuscript (RL, MEC); critical revision of the manuscript for important intellectual content (RL, MEC, MR, MJW, CC); statistical analysis (RL, MR); provision of study materials or patients (RL); obtaining funding (RL, MR); administrative, technical, or logistic support (MJW, CC); supervision (RL, MR); and development of CATI system and booklet (RL, MEC, MR, MJW, CC).

Address correspondence to: Roger Luckmann, MD, MPH, Dept Family Medicine and Community Health, UMass Medical School, 55 Lake Ave North, Worcester, MA 01655. E-mail: Roger.Luckmann@umassmemorial.org.
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