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IIR 04-042 – HSR&D Study

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IIR 04-042
Assessing and Addressing Patient Colorectal Cancer Screening Barriers
Melissa R. Partin PhD
Minneapolis VA Health Care System, Minneapolis, MN
Minneapolis, MN
Funding Period: July 2005 - March 2008

BACKGROUND/RATIONALE:
The overall goal of this study was to inform the development of interventions to increase colorectal cancer (CRC) screening among veterans age 50 and older.

OBJECTIVE(S):
The primary objectives were to: (1) estimate the relative effect of patient cognitive, environmental, and background factors on CRC screening behavior; (2) identify factors that contribute to any CRC screening disparities; and (3) identify priority targets for future interventions. Secondary objectives included assessing screening preferences.

METHODS:
This observational study involved conducting a nationally representative survey of 3744 veterans age 50-75 that received care from a VA facility in 2005 and 2006. The two-stage survey sample was drawn by first randomly selecting 24 facilities (stratified by size and racial mix), and then selecting a simple random sample of 156 eligible veterans from each sampled facility. The patient survey data on screening behaviors, attitudes, preferences, and demographics were linked to organizational-level data on CRC screening promotion strategies from the 2007 VA Clinical Practices Organizational Survey, facility complexity scores, and patient diagnoses and additional screening history information from VA administrative data. The
primary outcome was CRC screening adherence (i.e., self-report or medical records documentation of either a fecal occult blood test in the past 15 months, a sigmoidoscopy or double contrast barium enema in the past 5.5 years, or a colonoscopy in the past 11 years). Hierarchical logistic regression and structural equation modeling were used to examine the association between adherence and patient background, cognitive, and environmental factors. Additional regression analyses assessed patterns and determinants of screening disparities and mode preferences.

FINDINGS/RESULTS:
The survey response rate was 81% (n=3025). CRC screening adherence rates were 83% overall (75% among individuals with no personal history of colorectal polyps), but varied considerably across medical facilities (66-96%). Analyses exploring the relative effects of patient background, cognitive, and environmental factors on CRC screening adherence revealed that the effects of background factors on adherence were mediated by cognitive and environmental factors, and that cognitive and environmental factors contributed roughly equally to determining adherence rates. Additionally, we found that the effects of cognitive factors on adherence were moderated by physician recommendation to be screened (i.e., were more pronounced in the absence of a physician recommendation). Physician recommendation was found to be the strongest independent predictor of CRC screening adherence in our multivariate analyses (OR 2.82, p<.0001). However, only 16% of the average
risk individuals in our study sample indicated they had not received a physician recommendation for CRC screening. Similarly, although low perceived importance of CRC screening and lack of self-efficacy were significant predictors of adherence in our multivariate analyses, only a small fraction of patients in our sample reported these cognitive barriers to CRC screening. Organizational factors positively associated with adherence in the multivariate model were low organizational complexity (OR 1.46 in comparison to the most complex facilities, p=.008), and use of clinical champions (OR 1.71, p <.0001) and primary care provider training (OR 1.28, p=.0007) to promote adherence to CRC screening guidelines and protocols. Adherence rates were significantly lower among African Americans (70 vs 77%, p=.0003), veterans age 50-64 (72 vs 82%, p <.0001), and men (75 vs 89%, p=.05). The African American disadvantage in adherence was explained by background and environmental factors, but the age and gender disparities remained significant even after controlling for all background, cognitive and environmental factors. As hypothesized, colonoscopy (46%) and fecal occult blood testing (27%) were the most commonly preferred CRC screening modes.

IMPACT:
Given that so few of CRC screening eligible patients report cognitive barriers to screening, and that screening rates are relatively high overall, targeting facilities with the lowest screening rates may be a more efficient approach to increasing CRC screening adherence in the VA than implementing broad, population based interventions to address patient barriers.

PUBLICATIONS:

Journal Articles

  1. Burgess DJ, van Ryn M, Grill J, Noorbaloochi S, Griffin JM, Ricards J, Vernon SW, Fisher DA, Partin MR. Presence and correlates of racial disparities in adherence to colorectal cancer screening guidelines. Journal of general internal medicine. 2011 Mar 1; 26(3):251-8.
  2. Kodl MM, Powell AA, Noorbaloochi S, Grill JP, Bangerter AK, Partin MR. Mental health, frequency of healthcare visits, and colorectal cancer screening. Medical care. 2010 Oct 1; 48(10):934-9.
  3. Partin MR, Noorbaloochi S, Grill J, Burgess DJ, van Ryn M, Fisher DA, Griffin JM, Powell AA, Halek K, Bangerter A, Vernon SW. The interrelationships between and contributions of background, cognitive, and environmental factors to colorectal cancer screening adherence. Cancer Causes & Control : Ccc. 2010 Sep 1; 21(9):1357-68.
  4. Burgess DJ, Grill J, Noorbaloochi S, Griffin JM, Ricards J, van Ryn M, Partin MR. The effect of perceived racial discrimination on bodily pain among older African American men. Pain medicine (Malden, Mass.). 2009 Nov 1; 10(8):1341-52.
  5. Griffin JM, Burgess D, Vernon SW, Friedemann-Sanchez G, Powell A, van Ryn M, Halek K, Noorbaloochi S, Grill J, Bloomfield H, Partin M. Are gender differences in colorectal cancer screening rates due to differences in self-reporting? Preventive medicine. 2009 Nov 1; 49(5):436-41.
  6. Powell AA, Burgess DJ, Vernon SW, Griffin JM, Grill JP, Noorbaloochi S, Partin MR. Colorectal cancer screening mode preferences among US veterans. Preventive medicine. 2009 Nov 1; 49(5):442-8.
  7. Burgess DJ, Powell AA, Griffin JM, Partin MR. Race and the validity of self-reported cancer screening behaviors: development of a conceptual model. Preventive medicine. 2009 Feb 1; 48(2):99-107.
  8. Partin MR, Burgess DJ, Halek K, Grill J, Vernon SW, Fisher DA, Griffin JM, Murdoch M. Randomized trial showed requesting medical records with a survey produced a more representative sample than requesting separately. Journal of clinical epidemiology. 2008 Oct 1; 61(10):1028-35.
  9. Partin MR, Grill J, Noorbaloochi S, Powell AA, Burgess DJ, Vernon SW, Halek K, Griffin JM, van Ryn M, Fisher DA. Validation of self-reported colorectal cancer screening behavior from a mixed-mode survey of veterans. Cancer epidemiology, biomarkers & prevention : a publication of the American Association for Cancer Research, cosponsored by the American Society of Preventive Oncology. 2008 Apr 1; 17(4):768-76.
  10. Friedemann-Sánchez G, Griffin JM, Partin MR. Gender differences in colorectal cancer screening barriers and information needs. Health Expectations. 2007 Jun 1; 10(2):148-60.
Conference Presentations

  1. Burgess DJ. Racial and Ethnic Disparities in Pain: A Social Psychological Perspective. Presented at: Midwest Pain Society Annual Scientific Session; 2010 Oct 22; Chicago, IL.
  2. Powell AA, Nugent SM, Ordin DL, Noorbaloochi S, Partin MR. Pre-Post Evaluation of a VA Collaborative to Improve the Timeliness of Follow-Up after a Positive Colorectal Cancer Screening Test. Paper presented at: AcademyHealth Annual Research Meeting; 2010 Jun 28; Boston, MA.
  3. Burgess DJ, Noorbaloochi S, Griffin JM, Partin MR, Ricards J, Grill JP, van Ryn M, Vernon S, Fisher D. Presence and correlates of racial disparities in adherence to colorectal cancer screening guidelines. Paper presented at: Society of General Internal Medicine Annual Meeting; 2010 Apr 30; Minneapolis, MN.
  4. Burgess DJ, van Ryn M, Griffin JM, Grill J, Noorbaloochi S, Vernon SW, Fisher DA, Partin MR. Presence and correlates of racial disparities in adherence to colorectal cancer screening guidelines: Results of a national survey of veterans. Poster session presented at: AcademyHealth Annual Research Meeting; 2009 Jun 29; Chicago, IL.
  5. Burgess DJ, van Ryn M, Grill J, Noorbaloochi S, Griffin JM, Vernon S, Fisher D, Partin MR. Presence and correlates of racial disparities in adherence to colorectal cancer screening guidelines: Results of a national survey of veterans. Paper presented at: VA HSR&D National Meeting; 2009 Feb 12; Baltimore, MD.
  6. Partin MR, Noorbaloochi S, Grill J, Burgess DJ, van Ryn M, Fisher DA, Griffin JM, Powell AA, Yano E, Vernon SW. The contribution of patient background, cognitive, and environmental factors to colorectal cancer screening adherence. Paper presented at: VA HSR&D National Meeting; 2009 Feb 12; Baltimore, MD.
  7. Powell AA, Burgess DJ, Griffin JM, Vernon SW, Noorbaloochi S, Grill J, Partin MR. Distribution and Predictors of Colorectal Cancer Screening Mode Preferences among US Veterans. Paper presented at: VA HSR&D National Meeting; 2009 Feb 12; Baltimore, MD.
  8. Burgess D, van Ryn M, Griffin JM, Grill J, Partin MR. The association between experiences of discrimination and functional interference due to pain among older African American veterans. Poster session presented at: VA HSR&D National Meeting; 2008 Feb 14; Baltimore, MD.
  9. Partin MR, Grill J, Halek K, Vernon S, Noorbaloochi S, Powell AA, Griffin JM, Burgess D, van Ryn M, Fisher DA. Validation of Self-Reported Colorectal Cancer Screening Behavior Data Collected from a Mixed-mode Survey of Veterans. Paper presented at: VA HSR&D National Meeting; 2008 Feb 14; Baltimore, MD.
  10. Fisher, Partin MR, Halek K, Grill J, Noorbaloochi S, Vernon SW. Self-Reported Colorectal Cancer Screening Status: An Accurate Option for Practice and Research. Presented at: Digestive Disease Week / American Gastroenterological Association Annual Conference; 2007 Apr 1; Washington, DC.
  11. Partin MR, Burgess D, Halek K, Noorbaloochi S, Grill J, Fisher D, van Ryn M, Griffin J, Murdoch M, Vernon S. Maximizing Consent and Minimizing Bias: What is the Best Way to Request Permission to Access Patient Medical Records? Poster session presented at: VA HSR&D National Meeting; 2007 Feb 21; Arlington, VA.
  12. Partin MR. Barriers to colorectal cancer screening. Paper presented at: Minnesota Cancer Alliance's Cancer Annual Summit; 2006 Apr 25; Brooklyn Center, MN.


DRA: Health Systems
DRE: Diagnosis
Keywords: Research measure, Research method, Screening
MeSH Terms: none

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