Colorectal cancer is a disease with significant associated mortality and morbidity. Screening for colorectal cancer has been shown beneficial in reducing mortality and decreasing incidence of disease. However, adherence with current colorectal cancer screening recommendations is low. Within the VA, a significant number of veterans are not current with colorectal cancer screening. The VA has undergone an extensive re-organization in its health care delivery system and has adopted many system-level interventions directly impacting utilization of colorectal cancer screening. However, initial improvements have leveled off recently and a large number of veterans are still in need of being current with colorectal cancer screening. This highlights the need to adopt other interventions to augment the existing approaches to the delivery of colorectal cancer screening services in the VA. One area with little evaluation has been the patient-provider communication toward colorectal cancer screening. Recent work suggests that higher quality patient-provider communications (as perceived by patients) is associated with higher levels of colorectal cancer screening utilization. However, prior work by this research team suggests that communication content toward colorectal cancer screening between patients and providers is lacking. As such, we designed and implemented a multi-faceted communication intervention to significantly improve the communication process, content, and perception toward colorectal cancer screening. The intervention was administered in a clinically feasible manner using existing clinical personnel (i.e. prevention nurse) and a simple talking guide (i.e., single sheet) containing information relevant to colorectal cancer screening.
In this intervention, we aim to: (1) enhance the process of communication through the activation of patients by having the prevention nurse encourage the patient to initiate a colorectal cancer screening discussion with their primary care provider, (2) optimize communication content through a talking provided to the patient which will serve as a talking guide for the discussion, and (3) provide cues to the provider via the prompt sheet to assist in assessing the patient's perception of communication.
This study was conducted as a randomized controlled study at primary care clinics in three VA medical centers (Chicago, Houston, and Pittsburgh). The primary aim tested whether the intervention had a significant effect on increasing colorectal cancer screening test utilization. The patients in the experimental group were: (1) provided an information packet on colorectal cancer and screening that was mailed to them prior to the targeted clinic visit, (2) received encouragement from existing clinic personnel (i.e. prevention nurse) at the visit to initiate a colorectal cancer screening discussion, and (3) given a talking guide to be used with their primary care provider at the visit. The control group received only the information packet and otherwise was not exposed to any additional services beyond usual care. The clinical encounter was audiotaped and the medical record reviewed 6 months after the administration of the intervention to evaluate for the completion of colorectal cancer screening. An analysis of the audiotaped data (not yet undertaken) will assess whether the intervention affected the quality of patient-provider communication as well to test whether the quality of communication has an effect on patient utilization of colorectal cancer screening tests.
There were 37 providers enrolled with 20 assigned to the intervention group and 17 into the control group. From this group of providers, there were 454 patients enrolled into the study with 190 patients allocated to the intervention group and 264 into the control group. The enrollment by study site was as follows: 188 patients at Chicago (41.4%), 110 patients at Houston (24.2%), and 156 patients at Pittsburgh (34.4%). There were no differences between the intervention and control groups according to race, age, or family history of colorectal cancers/polyps. There a higher proportion of males in the control group (91.7%) compared to the intervention group (80.5%) (p<.001) and a higher proportion of greater than high school graduates in the intervention group (63.8%) compared to the control group (56.8%) (p=.05).
There was a high percentage of provider ordering of a colorectal cancer screening test with 94.3% of patients having either a fecal occult blood test or colonoscopy ordered by their PCP during the study period. There were no differences in ordering rates by intervention group, study site, or patient characteristics (i.e., race, age, gender, education level, or family history of colorectal cancer/polyp).
Overall, 53.7% of patients completed a colorectal cancer screening test during the study period with no differences between the intervention (53.7%) and control groups (53.8%). However, at the Pittsburgh site, a statistically significant higher percentage of intervention patients (69.6%) completed a colorectal cancer screening test during the study period compared to control group patients (51.7%) (p<.05). Conversely, at the Chicago site, there was a lower percentage of completion of colorectal cancer screening in the intervention group (29.2%) compared to the control group (47.4%) (p<.05) during the study period. There were no observed differences for completing colorectal cancer screening between the study groups according to race, age, education, or family history.
Using a multivariable logistic regression model with a random effect at the physician level to account for correlation between patients seeing the same physician, there was no effect of the intervention overall when controlling for patient characteristics (OR 0.86, 95% CI 0.5.7 - 1.31, p=0.49). We found a significant interaction (p<.01) between intervention and study site with those in the intervention group in Chicago less likely to complete screening (OR 0.47, 95% CI 0.24 - 0.90) whereas there was no effect of the intervention in Houston (OR 0.62, 95% CI 0.24 - 1.59) and a positive effect in Pittsburgh (OR 2.10, 95% CI 1.05 - 4.21).
According to patient self-report on the post-visit survey, nearly all of the visits contained a discussion on colorectal cancer screening (96.5%). There were no significant differences between the intervention and control groups with regard to having a colorectal cancer screening discussion or any of the specific communication items that were assessed. Furthermore, there were no significant differences in completing colorectal cancer screening during the study period between those who had gave the most favorable responses to the communication items with those who gave less favorable responses.
A large number of veterans are not current with colorectal cancer screening which has been shown to be a mortality-reducing preventive service. Overall, there did not seem to be an effect with the use of this talking guide. However, we did find that the talking guide increased use of colorectal cancer screening at one of the site while it decreased use of screening at another study site. The reasons for the different effect of the talking guide at the study sites are not known and require further study.
We did not find that the talking guide impacted how the patient perceived the communication with their primary care provider on the topic of colorectal cancer screening. Nor did self-report of the quality of the patient-provider communication seem to influence completion of colorectal cancer in this study. Further work will be conducted by this research team in this area by assessing the audiotapes that were collected during clinic visits between participating patients and their primary care providers as part of this study.
As such, widespread use of the talking guide used in this study would not be recommended at this time. However, we did find that it was beneficial at one of the study sites. Therefore, further work (such as evaluating the actual communication that occurred during the clinic visit) is needed to better understand the impact of the talking guide on patient-provider communication and its subsequent effects on completing colorectal cancer screening tests. This information would then be used to further refine or develop new interventions to improve colorectal cancer screening discussions as well as increase colorectal cancer screening rates.
- Ling BS, Trauth JM, Fine MJ, Mor MK, Resnick A, Braddock CH, Bereknyei S, Weissfeld JL, Schoen RE, Ricci EM, Whittle J. Informed decision-making and colorectal cancer screening: is it occurring in primary care? Medical care. 2008 Sep 1; 46(9 Suppl 1):S23-9.
- Ling BS, Trauth JM, Fine MJ, Mor MK, Braddock C, Bereknyei S, Weissfeld J, Schoen R, Whittle J. Communications on colorectal and prostate cancer screening: are patient perceptions consistent with actual information exchanged? Paper presented at: Society of General Internal Medicine Annual Meeting; 2008 Apr 9; Pittsburgh, PA.