- Email: [email protected]
Increasing referral rate for screening colonoscopy through patient education and activation at a primary care clinic in New York City
G Model PEC 5296 No. of Pages 5
Patient Education and Counseling xxx (2015) xxx–xxx
Contents lists available at ScienceDirect
Patient Education and Counseling journal homepage: www.elsevier.com/locate/pateducou
Short communication
Increasing referral rate for screening colonoscopy through patient education and activation at a primary care clinic in New York City Pathu Sriphanlop* , Marie Oliva Hennelly, Dylan Sperling, Cristina Villagra, Lina Jandorf Division of Cancer Prevention and Control, Department of Oncological Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA
A R T I C L E I N F O
A B S T R A C T
Article history: Received 10 September 2015 Received in revised form 1 March 2016 Accepted 4 March 2016
Objective: Colorectal cancer could be prevented through regular screening. Individuals age 50 and older are recommended to get screened via colonoscopy. Because physician referral is a major predictor of colonoscopy completion, two low-cost, evidence-based interventions were tested to increase referrals by activating patients to self-advocate. Methods: This study compared the impact of a pre-visit educational handout that prompts patients to discuss colonoscopy with their physician with the handout plus brief counseling through exit interviews and chart reviews. The main outcome was physician referral. Results: Medical charts were reviewed for eligibility: 130 control patients (Arm 1), 45 patients who received the educational handout and health counseling (Arm 2), and 50 patients who received only the handout (Arm 3). Colonoscopy referral rates increased from 24.6% in Arm 1 to 44.4% and 52.0% in Arms 2 and 3, respectively (p = 0.001). The proportion of exit interview participants who discussed colonoscopy with their doctor increased from 68.8% in Arm 1 to 76.5% and 88.9% in Arms 2 and 3, respectively. Conclusions: Results indicate that both interventions are effective at increasing colonoscopy referrals. Practical implications: Results suggest that an educational handout alone is sufficient in prompting patient-initiated discussions about colonoscopy. ã 2016 Elsevier Ireland Ltd. All rights reserved.
Keywords: Cancer Cancer screening Quality improvement Colonoscopy Colorectal cancer screening Patient education Patient activation
1. Introduction Colorectal cancer (CRC) is one of the leading causes of cancer mortality in the US. Despite significant advances in screening technology and the known benefits of early detection, lower CRC screening rates persist among minority and underserved populations [1,2]. It is recommended that individuals ages 50–74 get screened for CRC via colonoscopy every ten years [3]. Receiving a recommendation from a health care provider (HCP) is a significant predictor of colonoscopy completion [4–8]. Therefore, it is essential to find an effective and low-cost way to increase HCPs recommendations for screening colonoscopy. Patient-directed cues have been shown to increase both physician referral and colonoscopy completion. Cues may involve mailings, phone calls, or checklists, and are most effective when delivered in-person, with repeated exposures [6,9–13]. Cues may be successful because they overcome barriers to colonoscopy, including concern about patient anxiety/discomfort, patient
reluctance, prior patient refusal, physician forgetfulness, and lack of reminder systems [5,7,15]. Since physicians are more likely to order screening tests if they believe the patient will comply [14], patient-initiated request for colonoscopy may overcome physician-cited barriers to referrals. This is essential as current referral rates are lowest among low-income populations, contributing to racial/ethnic and socioeconomic disparities in CRC mortality [16]. Patient activation interventions have been shown to successfully increase CRC screening. Randomized controlled trials (RCTs) in primary care clinics with low-income populations have included providing CRC screening education, prompting patients to ask for screening, barriers-counseling via telephone, and web-based decision aids to encourage patients to discuss CRC screening with their doctors [18,19]. These have been shown to increase colonoscopy completion by 5–10% and referral rates by 11–21% [18,19]. Within studies of single-component interventions, inperson counseling has been found to increase patient participation more than written interventions [17]. 2. Materials and methods
* Corresponding author. E-mail address: [email protected] (P. Sriphanlop).
Two low-cost, evidence-based strategies were tested to increase colonoscopy referrals by activating patients to self-
http://dx.doi.org/10.1016/j.pec.2016.03.005 0738-3991/ ã 2016 Elsevier Ireland Ltd. All rights reserved.
Please cite this article in press as: P. Sriphanlop, et al., Increasing referral rate for screening colonoscopy through patient education and activation at a primary care clinic in New York City, Patient Educ Couns (2016), http://dx.doi.org/10.1016/j.pec.2016.03.005
G Model PEC 5296 No. of Pages 5
2
P. Sriphanlop et al. / Patient Education and Counseling xxx (2015) xxx–xxx
advocate for CRC screening. The intervention compared printed material (1-page; English and Spanish) prompting patients to discuss screening with their physician against printed material plus health counseling. The project focused on colonoscopy, as it can simultaneously detect and remove precancerous and cancerous lesions [3]. The purpose was to determine if a low-cost intervention was feasible and effective at activating patients to: (a) express their interest and/or willingness to receive CRC screening, and (b) directly ask their physicians for colonoscopy referrals. To assess the intervention’s effectiveness, we compared the referral rates of patients who did not receive any patient activation intervention (control group) with the two interventions. 2.1. Study sample In accordance with CRC screening guidelines, participant eligibility included individuals between 50 and 74 years of age with no personal or family history of CRC, English- and/or Spanishspeaking with no evidence of colonoscopy in the past ten years and had not received a colonoscopy referral in the past six months. Participants were recruited at the primary care clinic at Mount Sinai Hospital, NYC. Research staff reviewed patients’ electronic medical records to determine eligibility prior to their nonemergency appointment. Patients became ineligible for the study if they did not arrive for their appointment (Fig. 1). For the interventions, receptionists provided eligible patients with printed material at check in. The clinic serves a predominately low-income African American and Hispanic publically insured population.
usual care (no intervention). In the second month, eligible patients were provided the print material and received health counseling from a health educator. In the third month, eligible patients were provided with the print material only. Patients had the opportunity to read the print material in the waiting room before their visit. 2.3. Data collection Immediately after the visit, a brief exit interview was conducted in-person with a proportion of eligible patients in each study arm to assess the intervention’s impact. After eligible patients provided written informed consent, they completed a semi-structured survey. The interviews assessed receipt and use of the printed material (in Arms 2 and 3), whether a conversation occurred between provider and patient about CRC screening, content and characteristics of any such conversation (i.e., initiator, outcome), intent to undergo colonoscopy, and prior history of colonoscopy. Exit interviews were performed by research staff, and patients received a five dollar gift card for participating. Finally a chart review was conducted to assess past and current colonoscopy referrals, patient-provider discussions, race/ethnicity, and insurance status. 2.4. Measures The primary outcome variable was the number of patients referred for colonoscopy. Secondary outcomes included patient- or provider-initiated conversations about CRC screening and questions asked of the provider by the patient.
2.2. Study design
2.5. Statistical analysis
This IRB-approved study was carried out from January to March 2015. The pilot study consisted of three arms over three one-month periods. During the first month, eligible patients were provided
Categorical data were analyzed by Chi-square analysis. Continuous data were analyzed by t-test (SPSS v22). All tests of significance were two-sided using a p value < 0.05.
Fig. 1. Flowchart of study.
Please cite this article in press as: P. Sriphanlop, et al., Increasing referral rate for screening colonoscopy through patient education and activation at a primary care clinic in New York City, Patient Educ Couns (2016), http://dx.doi.org/10.1016/j.pec.2016.03.005
G Model PEC 5296 No. of Pages 5
P. Sriphanlop et al. / Patient Education and Counseling xxx (2015) xxx–xxx
3. Results
4. Discussion and conclusion
As shown in Fig. 1, 225 patients were eligible. In Arm 1, 130 patients were eligible and 32 (24.6%) received a colonoscopy referral. In Arm 2, 81 patients were eligible and 45 (55.6%) received an educational handout and health education counseling; 20 (44.4%) received a colonoscopy referral. In Arm 3, 99 patients were eligible and 50 (50.5%) received an educational handout; 26 (52.0%) received a colonoscopy referral. There were no socio-demographic differences in any of the three groups (Table 1). The difference in colonoscopy referral rates across the three arms was statistically significant at p = 0.001 (p = 0.01 between Arms 1 and 2). The difference was even more statistically significant between Arms 1 and 3 at p < 0.001. There was no statistically significant difference between Arms 2 and 3. Further, the Cohen’s d effect size indicates small or moderate effect between Arms 1 and 2 (d = 0.33) and moderate effect between Arms 1 and 3 (d = 0.50). Exit interviews were conducted with 16 Arm 1, 17 Arm 2, and 18 Arm 3 patients (Table 2). Most exit interview participants had spoken to a doctor about colonoscopy in the past (78.6%), however, 70.6% had never made a colonoscopy appointment. Although not statistically significant, the number of participants who reported discussing screening increased from 68.8% (Arm 1) to 76.5% and 88.9% in Arms 2 and 3, respectively. Among those who spoke to their doctor, the number of self-reported patient-initiated conversations increased from 8.3% in Arm 1 to 53.8% in Arm 2 and 23.5% in Arm 3. The differences in patient-initiated conversations were significant between Arms 1 and 2 (p = 0.02). Although there were no statistically significant differences in deciding to have a colonoscopy, being interested in getting a colonoscopy, and discussing CRC screening with their doctor, Arm 3 had the highest proportion of participants who favorably answered these questions.
4.1. Discussion
3
The findings indicate that an educational standalone handout could be sufficient and effective at activating patients to discuss CRC screening with their HCP. Exit interviews also support this as participants in Arm 3 had the highest proportion of intent to undergo colonoscopy and receipt of colonoscopy referral. Results are similar to past studies evaluating multiple activation strategies including patient education and telephone counseling (39% intervention vs. 18% control) aimed at activating patients to discuss CRC screening with their doctors, as well as other webbased decision aids (30% intervention vs. 21% control) [18,19]. Results support a low-cost pre-visit educational handout can effectively increase colonoscopy referral rates and patient-initiated discussions. 4.2. Limitations This study is not without limitations. We had an unequal number of participants in each arm, as the intervention was dependent on receptionists providing the educational handout. The receptionists were primed on the importance of providing the handout, however, they often forgot to give it out. As a result, only 55.6% and 50.5% of eligible patients were given the handout in Arms 2 and 3, respectively. A second limitation was the focus on colonoscopy. Additionally, we only examined colonoscopy referral not actual colonoscopy adherence, due to the time limitations associated with obtaining an appointment. Information related to HCP (e.g., amount of patients seen and differences in referrals made by each doctor) was not collected and could also have affected the results of the study. Lastly, the findings may not be generalizable to all primary care clinics.
Table 1 Results from chart review. Total (N = 225)
Arm 2: handout and education
Arm 3: handout only
N
%
N
%
N
%
N
%
142 83
63.1 36.9
81 49
62.3 37.7
30 15
66.7 33.3
31 19
62.0 38.0
Referred for colonoscopy at current appointmenta Yes 78 34.7 No 147 65.3
32 98
24.6 75.4
20 25
44.4 55.6
26 24
52.0 48.0
Referred for Colonoscopy in the past 6 to 12 monthsb Yes 43 20.7 No 165 79.3
26 96
21.3 78.7
10 30
22.2 66.7
7 39
14.0 78.0
Race/ethinicity Black/African American Caucasian Hispanic Other
81 27 83 34
36.0 12.0 36.9 15.1
49 17 42 22
37.7 13.1 32.3 16.9
17 4 18 6
37.8 8.9 40.0 13.3
15 6 23 6
30.0 12.0 46.0 12.0
Insurance typec Medicaid and/or medicare Private or self pay
193 32
14.2 85.8
116 14
89.2 10.8
37 8
82.2 17.8
40 10
80.0 20.0
Age
Mean 60.4
SD 6.8
Mean 60.8
SD 6.9
Mean 59.0
SD 7.1
Mean 60.7
SD 6.2
Gender Female Male
a b c
Arm 1: control
p-value comparing all 3 arms: p = 0.001; arm 1 vs. 2: p = 0.01; arm 1 vs. 3: p < 0.001; arm 2 vs. 3: p = 0.462. Associated with current colonoscopy referral at p = 0.02, however, no differences between 3 arms. Insurance associated with current colonoscopy referral at p = 0.05.
Please cite this article in press as: P. Sriphanlop, et al., Increasing referral rate for screening colonoscopy through patient education and activation at a primary care clinic in New York City, Patient Educ Couns (2016), http://dx.doi.org/10.1016/j.pec.2016.03.005
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P. Sriphanlop et al. / Patient Education and Counseling xxx (2015) xxx–xxx
Table 2 Results from exit interviews. Total N
Arm 2: handout & education
Arm 3: handout only
N
%
N
%
N
%
Have you ever discussed getting a colo with a doctor before? 30 58.8 11 Yes, a doctor at Mount Sinai Yes, a doctor elsewhere 10 19.6 1 No 11 21.6 4
68.8 6.3 25.0
11 3 3
64.7 17.6 17.6
8 6 4
44.4 33.3 22.2
Have you ever made a colonoscopy appointment in the past? 15 29.4 5 Yes No 36 70.6 11
31.3 68.8
4 13
23.5 76.5
6 12
33.3 66.7
Did you discuss CRC screening with your doctor today? Yes 40 78.4 No 11 21.6
11 5
68.8 31.3
13 4
76.5 23.5
16 2
88.9 11.1
If discussed, who brought up CRC screening?a Patient 12 Doctor 30
1 11
8.3 91.7
7 6
53.8 46.2
4 13
23.5 76.5
Did you ask your doctor questions about the colonoscopy? Yes 22 43.1 No 18 35.3
3 8
27.3 72.7
8 5
61.5 38.5
7 9
43.8 56.3
Did you decide to get a colonoscopy? Yes 35 No 15
10 6
62.5 37.5
10 7
58.8 41.2
15 2
88.2 11.8
Did your doctor give you a referral for a colonoscopy? Yes 32 65.3 No 17 34.7
9 6
60.0 40.0
11 6
64.7 35.3
12 5
70.6 29.4
Right, now are you interested in getting a colonoscopy? Yes 40 80.0 No 10 20.0
12 4
75.0 25.0
12 4
75.0 25.0
16 2
88.9 11.1
Race Black/African American Caucasian Latino/Hispanic Other
8 3 5 0
50.0 18.8 31.3 0.0
6 0 10 1
35.3 0.0 58.8 5.9
6 1 11 0
33.3 5.6 61.1 0.0
a
20 4 26 1
%
Arm 1: control
28.6 71.4
68.6 29.4
39.2 7.8 51.0 2.0
Significant difference between arms 1 and 2 (p = 0.02).
4.3. Conclusions
Acknowledgement
There is a need to increase colonoscopy referral rates and this study demonstrates that a cost-effective intervention is feasible and could be effective activating patients to speak to their HCP about colonoscopy, receive a referral, and increase patientinitiated conversations.
We would like to acknowledge the Icahn School of Medicine at Mount Sinai, Department of Medicine Advancing Clinical Excellence in Medicine grant program for funding this study. I confirm all patient/personal identifiers have been removed or disguised so the patient/person(s) described are not identifiable and cannot be identified through the details of the story.
4.4. Practical implications References Future research should explore whether a similar patient activation intervention could increase other cancer screenings and the potential cost-effectiveness of the intervention. The next steps for this project would be to integrate the educational handout with patients’ electronic health record and determine if this low-cost intervention is effective with an RCT. Different forms of patient education could also be tested and compared to the pre-visit educational handouts. Conflict of interest The authors have no conflict of interest to disclose.
[1] American Cancer Society, Colorectal Cancer Facts & Figures 2011–2013, American Cancer Society, 2011. [2] C.N. Klabunde, K.A. Cronin, N. Breen, et al., Trends in colorectal cancer test use among vulnerable populations in the United States, Cancer Epidemiol. Biomark. Prev. 20 (2011) 1611–1621. [3] U.S. Preventive Services Task Force, Screening for colorectal cancer: U.S. preventive Services Task Force recommendation statement, http://www. uspreventiveservicestaskforce.org/uspstf08/colocancer/colors.htm, published 2005 (accessed 13.02.14). [4] V. Taylor, D. Lessler, K. Mertens, et al., Colorectal cancer screening among African Americans: the importance of physician recommendation, J. Natl. Med. Assoc. 95 (2003) 806–812. [5] T.H. Feeley, J. Cooper, T. Foels, M.C. Mahoney, Efficacy expectations for colorectal cancer screening in primary care: identifying barriers and facilitators for patients and clinicians, Health Commun. 24 (2009) 304–315. [6] M. Sarfaty, R. Wender, How to increase colorectal cancer screening rates in practice, CA Cancer J. Clin. 57 (2007) 354–366.
Please cite this article in press as: P. Sriphanlop, et al., Increasing referral rate for screening colonoscopy through patient education and activation at a primary care clinic in New York City, Patient Educ Couns (2016), http://dx.doi.org/10.1016/j.pec.2016.03.005
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P. Sriphanlop et al. / Patient Education and Counseling xxx (2015) xxx–xxx [7] P. Brawarsky, D.R. Brooks, L.A. Mucci, P.A. Wood, Effect of physician recommendation and patient adherence on rates of colorectal cancer testing, Cancer Detect. Prev. 28 (2004) 260–268. [8] P. Brawarsky, D.R. Brooks, L.A. Mucci, Correlates of colorectal cancer testing in Massachusetts men and women, Prev. Med. 36 (2003) 659–668. [9] K.R. Yabroff, J.S. Mandelblatt, Interventions targeted toward patients to increase mammography use, Cancer Epidemiol. Biomark. Prev. 8 (1999) 749– 757. [10] S.J. Cohen, H.W. Halvorson, C.A. Gosselink, Changing physician behavior to improve disease prevention, Prev. Med. 23 (1994) 284–291. [11] B.J. Turner, S.C. Day, B. Borenstein, A controlled trial to improve delivery of preventive care: physician or patient reminders, J. Gen. Intern. Med. 4 (1989) 403–409. [12] R.C. Turner, L.E. Waivers, K. O’Brien, The effect of patient-carried reminder cards on the performance of health maintenance measures, Arch. Intern. Med. 150 (1990) 645–647. [13] R. Grol, J. Grimshaw, From best evidence to best practice: effective implementation of change in patients’ care, Lancet 362 (2003) 1225–1230.
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[14] P.A. Nutting, M. Baier, J.J. Werner, G. Cutter, C. Conry, L. Stewart, Competing demands in the office visit: what influences mammography recommendations, J. Am. Board Fam. Pract. 14 (2001) 352–361. [15] C.E. Guerra, J.S. Schwartz, K. Armstrong, J.S. Brown, C.H. Halbert, J.A. Shea, Barriers of and facilitators to physician recommendation of colorectal cancer screening, J. Gen. Intern. Med. 22 (2007) 1681–1688. [16] J. Swan, N. Breen, R.J. Coates, B.K. Rimer, N.C. Lee, Progress in cancer screening practices in the United States: results from the 2000 National Health Interview Survey, Cancer 97 (2003) 1528–1540. [17] J. Harrington, L.M. Noble, S.P. Newman, Improving patients’ communication with doctors: a systematic review of intervention studies, Patient Educ. Couns. 52 (2004) 7–16. [18] D.J. Cegala, T. Marinelli, D. Post, The effects of patient communication skills training on compliance, Arch. Fam. Med. 9 (2000) 57–64. [19] M.L. Katz, J.L. Fisher, K. Fleming, E.D. Paskett, Patient activation increases colorectal cancer screening rates: a randomized trial among low-income minority patients, Cancer Epidemiol. Biomark. Prev. 21 (2012) 45–52.
Please cite this article in press as: P. Sriphanlop, et al., Increasing referral rate for screening colonoscopy through patient education and activation at a primary care clinic in New York City, Patient Educ Couns (2016), http://dx.doi.org/10.1016/j.pec.2016.03.005
Patient Education and Counseling xxx (2015) xxx–xxx
Contents lists available at ScienceDirect
Patient Education and Counseling journal homepage: www.elsevier.com/locate/pateducou
Short communication
Increasing referral rate for screening colonoscopy through patient education and activation at a primary care clinic in New York City Pathu Sriphanlop* , Marie Oliva Hennelly, Dylan Sperling, Cristina Villagra, Lina Jandorf Division of Cancer Prevention and Control, Department of Oncological Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA
A R T I C L E I N F O
A B S T R A C T
Article history: Received 10 September 2015 Received in revised form 1 March 2016 Accepted 4 March 2016
Objective: Colorectal cancer could be prevented through regular screening. Individuals age 50 and older are recommended to get screened via colonoscopy. Because physician referral is a major predictor of colonoscopy completion, two low-cost, evidence-based interventions were tested to increase referrals by activating patients to self-advocate. Methods: This study compared the impact of a pre-visit educational handout that prompts patients to discuss colonoscopy with their physician with the handout plus brief counseling through exit interviews and chart reviews. The main outcome was physician referral. Results: Medical charts were reviewed for eligibility: 130 control patients (Arm 1), 45 patients who received the educational handout and health counseling (Arm 2), and 50 patients who received only the handout (Arm 3). Colonoscopy referral rates increased from 24.6% in Arm 1 to 44.4% and 52.0% in Arms 2 and 3, respectively (p = 0.001). The proportion of exit interview participants who discussed colonoscopy with their doctor increased from 68.8% in Arm 1 to 76.5% and 88.9% in Arms 2 and 3, respectively. Conclusions: Results indicate that both interventions are effective at increasing colonoscopy referrals. Practical implications: Results suggest that an educational handout alone is sufficient in prompting patient-initiated discussions about colonoscopy. ã 2016 Elsevier Ireland Ltd. All rights reserved.
Keywords: Cancer Cancer screening Quality improvement Colonoscopy Colorectal cancer screening Patient education Patient activation
1. Introduction Colorectal cancer (CRC) is one of the leading causes of cancer mortality in the US. Despite significant advances in screening technology and the known benefits of early detection, lower CRC screening rates persist among minority and underserved populations [1,2]. It is recommended that individuals ages 50–74 get screened for CRC via colonoscopy every ten years [3]. Receiving a recommendation from a health care provider (HCP) is a significant predictor of colonoscopy completion [4–8]. Therefore, it is essential to find an effective and low-cost way to increase HCPs recommendations for screening colonoscopy. Patient-directed cues have been shown to increase both physician referral and colonoscopy completion. Cues may involve mailings, phone calls, or checklists, and are most effective when delivered in-person, with repeated exposures [6,9–13]. Cues may be successful because they overcome barriers to colonoscopy, including concern about patient anxiety/discomfort, patient
reluctance, prior patient refusal, physician forgetfulness, and lack of reminder systems [5,7,15]. Since physicians are more likely to order screening tests if they believe the patient will comply [14], patient-initiated request for colonoscopy may overcome physician-cited barriers to referrals. This is essential as current referral rates are lowest among low-income populations, contributing to racial/ethnic and socioeconomic disparities in CRC mortality [16]. Patient activation interventions have been shown to successfully increase CRC screening. Randomized controlled trials (RCTs) in primary care clinics with low-income populations have included providing CRC screening education, prompting patients to ask for screening, barriers-counseling via telephone, and web-based decision aids to encourage patients to discuss CRC screening with their doctors [18,19]. These have been shown to increase colonoscopy completion by 5–10% and referral rates by 11–21% [18,19]. Within studies of single-component interventions, inperson counseling has been found to increase patient participation more than written interventions [17]. 2. Materials and methods
* Corresponding author. E-mail address: [email protected] (P. Sriphanlop).
Two low-cost, evidence-based strategies were tested to increase colonoscopy referrals by activating patients to self-
http://dx.doi.org/10.1016/j.pec.2016.03.005 0738-3991/ ã 2016 Elsevier Ireland Ltd. All rights reserved.
Please cite this article in press as: P. Sriphanlop, et al., Increasing referral rate for screening colonoscopy through patient education and activation at a primary care clinic in New York City, Patient Educ Couns (2016), http://dx.doi.org/10.1016/j.pec.2016.03.005
G Model PEC 5296 No. of Pages 5
2
P. Sriphanlop et al. / Patient Education and Counseling xxx (2015) xxx–xxx
advocate for CRC screening. The intervention compared printed material (1-page; English and Spanish) prompting patients to discuss screening with their physician against printed material plus health counseling. The project focused on colonoscopy, as it can simultaneously detect and remove precancerous and cancerous lesions [3]. The purpose was to determine if a low-cost intervention was feasible and effective at activating patients to: (a) express their interest and/or willingness to receive CRC screening, and (b) directly ask their physicians for colonoscopy referrals. To assess the intervention’s effectiveness, we compared the referral rates of patients who did not receive any patient activation intervention (control group) with the two interventions. 2.1. Study sample In accordance with CRC screening guidelines, participant eligibility included individuals between 50 and 74 years of age with no personal or family history of CRC, English- and/or Spanishspeaking with no evidence of colonoscopy in the past ten years and had not received a colonoscopy referral in the past six months. Participants were recruited at the primary care clinic at Mount Sinai Hospital, NYC. Research staff reviewed patients’ electronic medical records to determine eligibility prior to their nonemergency appointment. Patients became ineligible for the study if they did not arrive for their appointment (Fig. 1). For the interventions, receptionists provided eligible patients with printed material at check in. The clinic serves a predominately low-income African American and Hispanic publically insured population.
usual care (no intervention). In the second month, eligible patients were provided the print material and received health counseling from a health educator. In the third month, eligible patients were provided with the print material only. Patients had the opportunity to read the print material in the waiting room before their visit. 2.3. Data collection Immediately after the visit, a brief exit interview was conducted in-person with a proportion of eligible patients in each study arm to assess the intervention’s impact. After eligible patients provided written informed consent, they completed a semi-structured survey. The interviews assessed receipt and use of the printed material (in Arms 2 and 3), whether a conversation occurred between provider and patient about CRC screening, content and characteristics of any such conversation (i.e., initiator, outcome), intent to undergo colonoscopy, and prior history of colonoscopy. Exit interviews were performed by research staff, and patients received a five dollar gift card for participating. Finally a chart review was conducted to assess past and current colonoscopy referrals, patient-provider discussions, race/ethnicity, and insurance status. 2.4. Measures The primary outcome variable was the number of patients referred for colonoscopy. Secondary outcomes included patient- or provider-initiated conversations about CRC screening and questions asked of the provider by the patient.
2.2. Study design
2.5. Statistical analysis
This IRB-approved study was carried out from January to March 2015. The pilot study consisted of three arms over three one-month periods. During the first month, eligible patients were provided
Categorical data were analyzed by Chi-square analysis. Continuous data were analyzed by t-test (SPSS v22). All tests of significance were two-sided using a p value < 0.05.
Fig. 1. Flowchart of study.
Please cite this article in press as: P. Sriphanlop, et al., Increasing referral rate for screening colonoscopy through patient education and activation at a primary care clinic in New York City, Patient Educ Couns (2016), http://dx.doi.org/10.1016/j.pec.2016.03.005
G Model PEC 5296 No. of Pages 5
P. Sriphanlop et al. / Patient Education and Counseling xxx (2015) xxx–xxx
3. Results
4. Discussion and conclusion
As shown in Fig. 1, 225 patients were eligible. In Arm 1, 130 patients were eligible and 32 (24.6%) received a colonoscopy referral. In Arm 2, 81 patients were eligible and 45 (55.6%) received an educational handout and health education counseling; 20 (44.4%) received a colonoscopy referral. In Arm 3, 99 patients were eligible and 50 (50.5%) received an educational handout; 26 (52.0%) received a colonoscopy referral. There were no socio-demographic differences in any of the three groups (Table 1). The difference in colonoscopy referral rates across the three arms was statistically significant at p = 0.001 (p = 0.01 between Arms 1 and 2). The difference was even more statistically significant between Arms 1 and 3 at p < 0.001. There was no statistically significant difference between Arms 2 and 3. Further, the Cohen’s d effect size indicates small or moderate effect between Arms 1 and 2 (d = 0.33) and moderate effect between Arms 1 and 3 (d = 0.50). Exit interviews were conducted with 16 Arm 1, 17 Arm 2, and 18 Arm 3 patients (Table 2). Most exit interview participants had spoken to a doctor about colonoscopy in the past (78.6%), however, 70.6% had never made a colonoscopy appointment. Although not statistically significant, the number of participants who reported discussing screening increased from 68.8% (Arm 1) to 76.5% and 88.9% in Arms 2 and 3, respectively. Among those who spoke to their doctor, the number of self-reported patient-initiated conversations increased from 8.3% in Arm 1 to 53.8% in Arm 2 and 23.5% in Arm 3. The differences in patient-initiated conversations were significant between Arms 1 and 2 (p = 0.02). Although there were no statistically significant differences in deciding to have a colonoscopy, being interested in getting a colonoscopy, and discussing CRC screening with their doctor, Arm 3 had the highest proportion of participants who favorably answered these questions.
4.1. Discussion
3
The findings indicate that an educational standalone handout could be sufficient and effective at activating patients to discuss CRC screening with their HCP. Exit interviews also support this as participants in Arm 3 had the highest proportion of intent to undergo colonoscopy and receipt of colonoscopy referral. Results are similar to past studies evaluating multiple activation strategies including patient education and telephone counseling (39% intervention vs. 18% control) aimed at activating patients to discuss CRC screening with their doctors, as well as other webbased decision aids (30% intervention vs. 21% control) [18,19]. Results support a low-cost pre-visit educational handout can effectively increase colonoscopy referral rates and patient-initiated discussions. 4.2. Limitations This study is not without limitations. We had an unequal number of participants in each arm, as the intervention was dependent on receptionists providing the educational handout. The receptionists were primed on the importance of providing the handout, however, they often forgot to give it out. As a result, only 55.6% and 50.5% of eligible patients were given the handout in Arms 2 and 3, respectively. A second limitation was the focus on colonoscopy. Additionally, we only examined colonoscopy referral not actual colonoscopy adherence, due to the time limitations associated with obtaining an appointment. Information related to HCP (e.g., amount of patients seen and differences in referrals made by each doctor) was not collected and could also have affected the results of the study. Lastly, the findings may not be generalizable to all primary care clinics.
Table 1 Results from chart review. Total (N = 225)
Arm 2: handout and education
Arm 3: handout only
N
%
N
%
N
%
N
%
142 83
63.1 36.9
81 49
62.3 37.7
30 15
66.7 33.3
31 19
62.0 38.0
Referred for colonoscopy at current appointmenta Yes 78 34.7 No 147 65.3
32 98
24.6 75.4
20 25
44.4 55.6
26 24
52.0 48.0
Referred for Colonoscopy in the past 6 to 12 monthsb Yes 43 20.7 No 165 79.3
26 96
21.3 78.7
10 30
22.2 66.7
7 39
14.0 78.0
Race/ethinicity Black/African American Caucasian Hispanic Other
81 27 83 34
36.0 12.0 36.9 15.1
49 17 42 22
37.7 13.1 32.3 16.9
17 4 18 6
37.8 8.9 40.0 13.3
15 6 23 6
30.0 12.0 46.0 12.0
Insurance typec Medicaid and/or medicare Private or self pay
193 32
14.2 85.8
116 14
89.2 10.8
37 8
82.2 17.8
40 10
80.0 20.0
Age
Mean 60.4
SD 6.8
Mean 60.8
SD 6.9
Mean 59.0
SD 7.1
Mean 60.7
SD 6.2
Gender Female Male
a b c
Arm 1: control
p-value comparing all 3 arms: p = 0.001; arm 1 vs. 2: p = 0.01; arm 1 vs. 3: p < 0.001; arm 2 vs. 3: p = 0.462. Associated with current colonoscopy referral at p = 0.02, however, no differences between 3 arms. Insurance associated with current colonoscopy referral at p = 0.05.
Please cite this article in press as: P. Sriphanlop, et al., Increasing referral rate for screening colonoscopy through patient education and activation at a primary care clinic in New York City, Patient Educ Couns (2016), http://dx.doi.org/10.1016/j.pec.2016.03.005
G Model PEC 5296 No. of Pages 5
4
P. Sriphanlop et al. / Patient Education and Counseling xxx (2015) xxx–xxx
Table 2 Results from exit interviews. Total N
Arm 2: handout & education
Arm 3: handout only
N
%
N
%
N
%
Have you ever discussed getting a colo with a doctor before? 30 58.8 11 Yes, a doctor at Mount Sinai Yes, a doctor elsewhere 10 19.6 1 No 11 21.6 4
68.8 6.3 25.0
11 3 3
64.7 17.6 17.6
8 6 4
44.4 33.3 22.2
Have you ever made a colonoscopy appointment in the past? 15 29.4 5 Yes No 36 70.6 11
31.3 68.8
4 13
23.5 76.5
6 12
33.3 66.7
Did you discuss CRC screening with your doctor today? Yes 40 78.4 No 11 21.6
11 5
68.8 31.3
13 4
76.5 23.5
16 2
88.9 11.1
If discussed, who brought up CRC screening?a Patient 12 Doctor 30
1 11
8.3 91.7
7 6
53.8 46.2
4 13
23.5 76.5
Did you ask your doctor questions about the colonoscopy? Yes 22 43.1 No 18 35.3
3 8
27.3 72.7
8 5
61.5 38.5
7 9
43.8 56.3
Did you decide to get a colonoscopy? Yes 35 No 15
10 6
62.5 37.5
10 7
58.8 41.2
15 2
88.2 11.8
Did your doctor give you a referral for a colonoscopy? Yes 32 65.3 No 17 34.7
9 6
60.0 40.0
11 6
64.7 35.3
12 5
70.6 29.4
Right, now are you interested in getting a colonoscopy? Yes 40 80.0 No 10 20.0
12 4
75.0 25.0
12 4
75.0 25.0
16 2
88.9 11.1
Race Black/African American Caucasian Latino/Hispanic Other
8 3 5 0
50.0 18.8 31.3 0.0
6 0 10 1
35.3 0.0 58.8 5.9
6 1 11 0
33.3 5.6 61.1 0.0
a
20 4 26 1
%
Arm 1: control
28.6 71.4
68.6 29.4
39.2 7.8 51.0 2.0
Significant difference between arms 1 and 2 (p = 0.02).
4.3. Conclusions
Acknowledgement
There is a need to increase colonoscopy referral rates and this study demonstrates that a cost-effective intervention is feasible and could be effective activating patients to speak to their HCP about colonoscopy, receive a referral, and increase patientinitiated conversations.
We would like to acknowledge the Icahn School of Medicine at Mount Sinai, Department of Medicine Advancing Clinical Excellence in Medicine grant program for funding this study. I confirm all patient/personal identifiers have been removed or disguised so the patient/person(s) described are not identifiable and cannot be identified through the details of the story.
4.4. Practical implications References Future research should explore whether a similar patient activation intervention could increase other cancer screenings and the potential cost-effectiveness of the intervention. The next steps for this project would be to integrate the educational handout with patients’ electronic health record and determine if this low-cost intervention is effective with an RCT. Different forms of patient education could also be tested and compared to the pre-visit educational handouts. Conflict of interest The authors have no conflict of interest to disclose.
[1] American Cancer Society, Colorectal Cancer Facts & Figures 2011–2013, American Cancer Society, 2011. [2] C.N. Klabunde, K.A. Cronin, N. Breen, et al., Trends in colorectal cancer test use among vulnerable populations in the United States, Cancer Epidemiol. Biomark. Prev. 20 (2011) 1611–1621. [3] U.S. Preventive Services Task Force, Screening for colorectal cancer: U.S. preventive Services Task Force recommendation statement, http://www. uspreventiveservicestaskforce.org/uspstf08/colocancer/colors.htm, published 2005 (accessed 13.02.14). [4] V. Taylor, D. Lessler, K. Mertens, et al., Colorectal cancer screening among African Americans: the importance of physician recommendation, J. Natl. Med. Assoc. 95 (2003) 806–812. [5] T.H. Feeley, J. Cooper, T. Foels, M.C. Mahoney, Efficacy expectations for colorectal cancer screening in primary care: identifying barriers and facilitators for patients and clinicians, Health Commun. 24 (2009) 304–315. [6] M. Sarfaty, R. Wender, How to increase colorectal cancer screening rates in practice, CA Cancer J. Clin. 57 (2007) 354–366.
Please cite this article in press as: P. Sriphanlop, et al., Increasing referral rate for screening colonoscopy through patient education and activation at a primary care clinic in New York City, Patient Educ Couns (2016), http://dx.doi.org/10.1016/j.pec.2016.03.005
G Model PEC 5296 No. of Pages 5
P. Sriphanlop et al. / Patient Education and Counseling xxx (2015) xxx–xxx [7] P. Brawarsky, D.R. Brooks, L.A. Mucci, P.A. Wood, Effect of physician recommendation and patient adherence on rates of colorectal cancer testing, Cancer Detect. Prev. 28 (2004) 260–268. [8] P. Brawarsky, D.R. Brooks, L.A. Mucci, Correlates of colorectal cancer testing in Massachusetts men and women, Prev. Med. 36 (2003) 659–668. [9] K.R. Yabroff, J.S. Mandelblatt, Interventions targeted toward patients to increase mammography use, Cancer Epidemiol. Biomark. Prev. 8 (1999) 749– 757. [10] S.J. Cohen, H.W. Halvorson, C.A. Gosselink, Changing physician behavior to improve disease prevention, Prev. Med. 23 (1994) 284–291. [11] B.J. Turner, S.C. Day, B. Borenstein, A controlled trial to improve delivery of preventive care: physician or patient reminders, J. Gen. Intern. Med. 4 (1989) 403–409. [12] R.C. Turner, L.E. Waivers, K. O’Brien, The effect of patient-carried reminder cards on the performance of health maintenance measures, Arch. Intern. Med. 150 (1990) 645–647. [13] R. Grol, J. Grimshaw, From best evidence to best practice: effective implementation of change in patients’ care, Lancet 362 (2003) 1225–1230.
5
[14] P.A. Nutting, M. Baier, J.J. Werner, G. Cutter, C. Conry, L. Stewart, Competing demands in the office visit: what influences mammography recommendations, J. Am. Board Fam. Pract. 14 (2001) 352–361. [15] C.E. Guerra, J.S. Schwartz, K. Armstrong, J.S. Brown, C.H. Halbert, J.A. Shea, Barriers of and facilitators to physician recommendation of colorectal cancer screening, J. Gen. Intern. Med. 22 (2007) 1681–1688. [16] J. Swan, N. Breen, R.J. Coates, B.K. Rimer, N.C. Lee, Progress in cancer screening practices in the United States: results from the 2000 National Health Interview Survey, Cancer 97 (2003) 1528–1540. [17] J. Harrington, L.M. Noble, S.P. Newman, Improving patients’ communication with doctors: a systematic review of intervention studies, Patient Educ. Couns. 52 (2004) 7–16. [18] D.J. Cegala, T. Marinelli, D. Post, The effects of patient communication skills training on compliance, Arch. Fam. Med. 9 (2000) 57–64. [19] M.L. Katz, J.L. Fisher, K. Fleming, E.D. Paskett, Patient activation increases colorectal cancer screening rates: a randomized trial among low-income minority patients, Cancer Epidemiol. Biomark. Prev. 21 (2012) 45–52.
Please cite this article in press as: P. Sriphanlop, et al., Increasing referral rate for screening colonoscopy through patient education and activation at a primary care clinic in New York City, Patient Educ Couns (2016), http://dx.doi.org/10.1016/j.pec.2016.03.005