Systematic Review: Enhancing the Use and Quality of Colorectal Cancer Screening
ABSTRACT National guideline groups recommend screening and discussion of screening options for persons at average risk for colorectal cancer (CRC). However, emerging evidence suggests that CRC screening is simultaneously underused, overused, and misused and that adequate patient-provider discussions about screening are infrequent.
To summarize evidence on factors that influence CRC screening and strategies that increase the appropriate use and quality of CRC screening and CRC screening discussions.
MEDLINE, the Cochrane Library, and the Cochrane Central Register of Controlled Trials were searched for English-language publications describing studies conducted in the United States from January 1998 through September 2009.
Two reviewers independently selected studies that addressed the study questions and met eligibility criteria.
Information on study design, setting, intervention, outcomes, and quality were extracted by one reviewer and double-checked by another. Reviewers assigned a strength-of-evidence grade for intervention categories by using criteria plus a consensus process.
Reviewers found evidence of simultaneous underuse, overuse, and misuse of CRC screening as well as inadequate clinical discussions about CRC screening. Several patient-level factors were independently associated with lower screening rates, including having low income or less education, being uninsured, being Hispanic or Asian, being less acculturated into the United States, or having limited access to care. Evidence that interventions that included patient reminders or one-on-one interactions (that is, between patients and nonphysician clinic staff), eliminated structural barriers (for example, simplifying access to fecal occult blood test cards), or made system-level changes (for example, using systematic screening as opposed to opportunistic screening) were effective in enhancing use of CRC screening was strong. Evidence on how best to enhance discussions about CRC screening options is limited. No studies focused on reducing overuse, and very few focused on misuse.
Reporting and publication bias may have affected our findings. The independent effect of individual elements of multicomponent interventions was often uncertain.
Although CRC screening is underused overall, important problems of overuse and misuse also exist. System- and policy-level interventions that target vulnerable populations are needed to reduce underuse. Interventions aimed at reducing barriers by making the screening process easier are likely to be effective. Studies aimed at reducing overuse and misuse and at enhancing the quality and frequency of discussions about CRC screening options are needed.
Agency for Healthcare Research and Quality.
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ABSTRACT: Precise diagnostic coding of procedures is of critical importance for accurate billing, determination of patient co-pays and deductibles, retrospective analysis of results, and development of performance metrics. For example, whether a colonoscopy is coded as diagnostic or therapeutic, screening or surveillance has important implications for determining patient's personal cost, deriving an endoscopists' adenoma detection rate and understanding appropriate use of the procedure. In this month's "Practice Management: The Road Ahead" article, Dr. Amit G. Singal and colleagues help us wade through the terminology and implications of procedural coding. As more refined electronic reporting systems are developed, we hope that standardization of terminology becomes more robust. Only with a more standardized coding and indication documentation can we hope to derive accurate population level information.Clinical Gastroenterology and Hepatology 12/2014; 12(12):1958-63.e1-3. DOI:10.1016/j.cgh.2014.09.028 · 6.53 Impact Factor
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ABSTRACT: Colorectal cancer (CRC) screening rates are low among vulnerable populations. Fecal immunochemical tests (FITs) are one screening modality with few barriers. Studies have shown that outreach can improve CRC screening, but little is known about its effectiveness among individuals with no CRC screening history. We sought to determine whether outreach increases FIT uptake among patients with no CRC screening history compared to usual care. This study was a patient-level randomized controlled trial, including 420 patients who had never completed CRC screening and were eligible for FIT; 66 % were female, 62.1 % were Latino, and 70.7 % were uninsured. The main outcome measure was FIT completion within 6 months of the randomization date. We assessed FIT completion at different time points corresponding to receipt of outreach components. All analyses were re-run with 12-month data. Patients who received outreach were more likely to complete FIT than those in usual care (36.7 % vs. 14.8 %; p < 0.001). FIT completion was more common among patients with increased clinic visits. The difference in FIT completion between the outreach and usual care groups decreased over time. The intervention improved FIT uptake among patients with no CRC screening history. However, the intervention was less effective than in a previous trial targeting patients due for repeat screening. Additional research is needed to determine the best methods for improving CRC screening among this hard-to-reach group.Journal of General Internal Medicine 03/2015; DOI:10.1007/s11606-015-3234-5 · 3.42 Impact Factor
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ABSTRACT: The US Preventive Services Task Force recommends patient-physician discussions about the appropriateness of colorectal cancer (CRC) screening among adults ages 76-84 years who have never been screened. In this study, we used data from the 2010 National Health Interview Survey to examine patterns of CRC screening and provider recommendation among seniors ages 76-84 years, and made some comparisons to younger adults. Nationally-representative samples of 1379 adults ages 76-84 years and 8797 adults ages 50-75 years responded to questions about CRC screening status, receipt of provider recommendation, and discussion of test options; 22.7 % (95 % CI 20.1-25.3) of seniors ages 76-84 had never been tested for CRC and therefore were not up-to-date with guidelines; 3.9 % (95 % CI 2.0-7.6) of these individuals reported a recent provider recommendation for screening. In multivariate analyses, the likelihood of never having been tested was significantly greater for seniors of other/multiple race or Hispanic ethnicity; with high school or less education; without private health insurance coverage; who had ≤1 doctor visit in the past year; without recent screening for breast, cervical, or prostate cancer; with no or unknown CRC family history; or with ≤1 chronic disease. Among the minority of respondents ages 50-75 and 76-84 reporting a provider recommendation, 73.2 % indicated that the provider recommended particular tests, which was overwhelmingly colonoscopy (≥89 %). Nearly one-quarter of adults 76-84 have never been screened for CRC, and rates of provider recommendation in this group are very low. Greater attention to informed CRC screening discussions with screening-eligible seniors is needed.Journal of Community Health 02/2015; DOI:10.1007/s10900-015-9998-z · 1.28 Impact Factor