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.
"To meet this challenge, tailored methods such as phone call interventions are being developed in addition to the standard postal approach. Phone calls are reportedly more effective (Rimer & Lipscomb, 2000) and cost-effective (Majowicz et al., 2004) than letters owing to the direct verbal exchange between the healthcare professional and the beneficiary (Holden et al., 2010). Indeed, it is thought that tailored phone counseling is two-fold more efficient than standard mailing (Prochaska et al., 2001). "
[Show abstract][Hide abstract] ABSTRACT: Introduction. – While high participation rates ensure the cost-effectiveness of colorectal cancer screening programs, it is well known that postal requests do not achieve acceptable levels of participation.
Objective. – This randomized controlled study aimed to testthe impact ofindividualized phone counseling
to prompt people aged 50 to 74 to take a colorectal cancer test.
Method. – Two phone strategies were compared. The first involved computer-aided individualized counseling while the second was based on motivational interviewing. A total of 49,972 people were randomly assigned to a control group (CG) and to the individualized counseling (IC) and motivational interviewing (MI) telephone groups.
Results. – A simple call doubled the participation rate per protocol (19.2% > 9.2%; p < .001; r = .131;
OR = 2.374), and tripled it when the interview was conducted (30.4% > 9.2%; p < .001; r = .219; OR = 4.321). In an intention-to-treat analysis, the benefit of calling by phone remained even higher than postal
requests (10% > 9.2%; p < .01; r = .014; OR = 1.103). However, there was no impact of the type of interview
on participation rates.
Conclusion. – The results are discussed for future research
"Despite increases in screening rates in the last decade , only 65% of US adults are up to date with recommended screening, and only about 47% of US Latino adults [6,7]. Members of vulnerable groups, including racial or ethnic minorities, the uninsured, and Medicaid populations have the lowest screening rates in the USA . The many patient-, provider-, and system-level barriers that inhibit the CRC screening process disproportionately affect vulnerable groups. "
[Show abstract][Hide abstract] ABSTRACT: Background
Screening can reduce colorectal cancer (CRC) incidence and mortality. However, screening is underutilized in vulnerable patient populations, particularly among Latinos. Patient-directed decision aids can increase CRC screening knowledge, self-efficacy, and intent; however, their effect on actual screening test completion tends to be modest. This is probably because decision aids do not address some of the patient-specific barriers that prevent successful completion of CRC screening in these populations. These individual barriers might be addressed though patient navigation interventions. This study will test a combined decision aid and patient navigator intervention on screening completion in diverse populations of vulnerable primary care patients.
We will conduct a multisite, randomized controlled trial with patient-level randomization. Planned enrollment is 300 patients aged 50 to 75 years at average CRC risk presenting for appointments at two primary clinics in North Carolina and New Mexico. Intervention participants will view a video decision aid immediately before the clinic visit. The 14 to 16 minute video presents information about fecal occult blood tests and colonoscopy and will be viewed on a portable computer tablet in English or Spanish. Clinic-based patient navigators are bilingual and bicultural and will provide both face-to-face and telephone-based navigation. Control participants will view an unrelated food safety video and receive usual care. The primary outcome is completion of a CRC screening test at six months. Planned subgroup analyses include examining intervention effectiveness in Latinos, who will be oversampled. Secondarily, the trial will evaluate the intervention effects on knowledge of CRC screening, self-efficacy, intent, and patient-provider communication. The study will also examine whether patient ethnicity, acculturation, language preference, or health insurance status moderate the intervention effect on CRC screening.
This pragmatic randomized controlled trial will test a combined decision aid and patient navigator intervention targeting CRC screening completion. Findings from this trial may inform future interventions and implementation policies designed to promote CRC screening in vulnerable patient populations and to reduce screening disparities.
Clinical trial registration
"The demographic variables found to be associated with an increased likelihood of screening participation were generally consistent with prior studies, including having health insurance coverage, older age, higher educational attainment, and higher income (Beydoun and Beydoun, 2008; Gimeno García, 2012; Holden et al., 2010). Also, the negative association between aggregate screening knowledge and age found in the present study is somewhat consistent with analyses of the 2003 Health Information National Trends Survey of adults aged 65 and older, which found that those aged 75–89 exhibited less screening knowledge than those aged 65–74 (Berkowitz et al., 2008). "
[Show abstract][Hide abstract] ABSTRACT: Colorectal cancer screening has been widely promoted in the United States. We investigated the association between reported exposure to screening information during the past year and screening participation and knowledge.
Data from the 2012 HealthStyles Fall survey of U.S. adults were examined using adjusted logistic regression to examine the frequency of exposure to screening information as a predictor of screening participation and knowledge; analyses were limited to participants aged ≥50 years with no history of colorectal cancer or polyps (N=1,714).
Nearly half of participants (44.9%) reported exposure to colorectal cancer screening information during the previous year. The most common sources of screening information were news reports, advertisements, and health care providers. Screening participation and knowledge consistently increased with the reported frequency of exposure to screening information, and these associations generally persisted when demographic variables were controlled. Compared with unexposed participants, significant gains in screening participation were associated with exposure to screening information 2-3 times (Adj. OR= 1.84, p=0.001), 4-9 times (Adj. OR= 2.00, p=0.001), and ≥10 times (Adj. OR= 3.03, p<0.001) in the adjusted model.
Increasing public exposure to screening promotion messages may augment screening participation and knowledge.
Preventive Medicine 12/2013; 60. DOI:10.1016/j.ypmed.2013.12.001 · 3.09 Impact Factor
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