Of 17 performance measures of hospital quality regularly reported for the Veterans Administration (VA) health care system, rates of colorectal cancer screening are the lowest.
The objectives of this study were to 1) test whether a health care provider-directed intervention increased colorectal cancer screening rates in an urban VA medical center and 2) evaluate the cost-effectiveness of the intervention.
The study was a randomized controlled trial, conducted at two clinic firms at a VA Medical Center in Chicago. Eligible patients were men, age 50 and older, 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 4-6 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. In the cost-effectiveness analysis, resource and cost estimates were derived.
Among 1978 Veterans included in the study, colorectal cancer screening was recommended for 76.0% of patients in the intervention firm and for 69.4% of controls (p=0.02). Screening tests were completed by 41.3% of patients in the intervention group versus 32.4% of controls (p=0.003). Rates of colorectal screening for the intervention versus control arm were 41.3% versus 32.4%. The cost of the feedback program based on data reports generated from manual review of medical records was $86,753, and the incremental cost-effectiveness ratio was $978 per additional Veteran screened. However, if quarterly feedback data reports could be generated directly by information technology systems, the cost estimates decreased to $17,341 and $196, respectively.
Studies have shown that adults with low education levels and low-income suffer disproportionately high levels of cancer incidence, advanced cancers at presentation and mortality, and are less likely to be screened for cancer. VA has identified low literacy as a significant problem among its patient population and a priority area for research. The project will help identify the colorectal cancer screening information needs of patients with limited literacy skills and will develop and test the efficacy of colorectal cancer screening education programs specifically designed for these patients and their MDs. The results of this study will provide a foundation for future interventions designed for low socioeconomic status and minority populations.
Low literacy is associated with poorer knowledge and more negative attitudes toward CRC screening and may be an overlooked screening barrier. This intervention, targeted to men with low literacy, significantly increased CRC screening among Veterans, especially those with inadequate literacy.
External Links for this Project
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