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Race and Response to Colon Cancer Screening Interventions
80 Race and Response to Colon Cancer Screening Interventions Ali A. Siddiqui, Randa Sifri, Terry Hyslop, Jocelyn Andrel, Michael P. Rosenthal, Sally W. Vernon, James Cocroft, Ronald E. Myers Introduction: Research studies have shown that colorectal cancer (CRC) screening among primary care patients can be increased by using different types of patient-oriented behavioral interventions. However the impact of such interventions on CRC screening disparities has not been studied. Aim: We report the differential response of white and African American primary care patients to behavioral interventions intended to increase CRC screening. Methods: A randomized trial was conducted with 1,546 patients who were 50-74 years of age and were eligible for CRC screening. Participants were randomized to one of 4 groups: Control (Usual Care), Standard Intervention (SI), Tailored Intervention (TI), or Tailored Intervention plus Phone (TIP). The SI Group received a targeted intervention by mail. The TI Group received the targeted intervention with tailored message pages. The TIP Group received the targeted intervention, tailored message pages, and a telephone reminder. Screening was measured completion of any guidelines-recommended test following randomization. Multivariable analyses were completed to assess intervention impact on screening and racerelated screening disparity. Results: For 1,430 study participants with complete data (578 whites and 852 African Americans), CRC screening rates were significantly higher (p<0.001) in the SI, TI, and TIP groups (47%, 44%, and 50%) versus control group patients (32%). Although, screening rates for whites and African Americans were comparable in usual care (33% vs. 32%, respectively; OR=1.01, 95% CI=0.64-1.61), whites exhibited significantly higher rates than African Americans in response to any intervention (53% and 43%, respectively; OR=1.44, 95% CI=1.12-1.86). This effect is largely accounted for by exposure to the SI Group mailed print intervention. Exposure to mailed materials in the SI Group resulted in more screening among whites than African Americans (55% and 41% respectively, OR = 1.68; 95% CI=1.10, 2.58) (Table 1). Conclusions: Findings from this study suggest that whites and African Americans may respond differently to interventions intended to increase CRC screening. Mailed interventions may serve to increase CRC screening, but may also produce unintended disparities in screening adherence. Table 1. Multivariable Analysis of CRC Screening by Study Group and Race (n=1,430)
87 Insurance Coverage for Screening Colonoscopy at Age 45 for African Americans: Low Adherence to Guidelines in States With Large African American Populations Lance T. Uradomo, Andrew Mener, Marie L. Borum Purpose: African Americans (AA) are at increased risk of colorectal cancer. The American College of Gastroenterology (ACG) Colorectal Cancer Screening Guidelines recommend that African Americans initiate screening at age 45 rather than 50. This study investigates whether insurers have adjusted screening coverage to reflect the new guidelines. The study also explores the ease of access to online information regarding coverage. Methods: Insurance companies were selected from the four US states with the largest AA populations: New York (NY), Texas (TX), Georgia (GA), Florida (FL), as well as the District of Columbia (DC), which has the highest percentage of AA. Companies were selected based on lists from each state's Insurance Commissioner. Those operating in multiple states were counted separately in each state. Companies that only offer Medicare Advantage Plans or do not market to individuals were excluded. Each company's website was accessed by a study co-author and 30 minutes was allocated to identify coverage policies. If unsuccessful, additional time was used to search the terms “colonoscopy,” “colorectal,” “screening,” and “preventive,” using the website's search field and then Google's “advanced search” of the website. The first 2 pages of results from each search were explored. Educational materials recommending screening were not assumed to be evidence of coverage, while a posted company guideline was. Proportions were compared with Fisher exact and chi-square tests. Results: Sixty companies were included. Specific statements or policies indicating coverage for AA at age 45 were found for 10 (16.7%). One additional company listed “special consideration” for AA without details. Coverage for AA at age 45 was found in 3 of 13 (23%) in NY, 2 of 13 (15.4%) in TX, 2 of 10 (20%) in GA, 1 of 18 (5.6%) in FL, and 2 of 6 (33.3%) in DC. Coverage at age 50 was found in 30 companies (50%) while 2 (3.3%) did not specify age. Information was found by surfing the main webpage in 14 cases (23.3%). The website search field found the data in 22 (38.3%) cases, while an advanced search identified 12 (20%) policies. No information was found in 17 cases (28.3%). There were no statistically significant differences in the coverage or the ease of finding information between states. Conclusion: Even in states with the largest African American populations, most insurers have not adopted the new ACG guideline. Coverage information was rarely easily accessible on the insurers' websites. Searches using multiple terms were required, and frequently the website's search engine had to be supplemented by an advanced search. The difficulty in finding the information may hinder average consumers in making informed decisions when choosing an insurer. 88 Differences in Knowledge, Attitudes, Beliefs, and Perceived Risks Regarding Colorectal Cancer Screening Among Chinese, Korean, and Vietnamese SubGroups T Domi Le, Patricia A. Carney, Frances Lee-Lin, Holden Leung, Christine Lau, Motomi Mori, Zunqiu Chen, David A. Lieberman
*Adjusted for age, education, and marital status 81
BACKGROUND Colorectal cancer (CRC) screening in average-risk asymptomatic populations has been shown to reduce mortality from CRC. CRC screening rates among Asian Americans, a rapidly growing population in the United States, remain lower than that of Caucasians. Reasons for this disparity are unclear and may include lack of knowledge, language barriers, and cultural beliefs that do not promote screening. Asian Americans include sub-populations with diverse cultural backgrounds that may influence beliefs about CRC screening. Interventions that target Asians may not be effective if they do not adequately address these barriers. This study aimed to assess differences in knowledge, attitudes, and beliefs on CRC screening among Chinese, Korean, and Vietnamese groups. METHODS 639 Asian Americans met inclusion criteria and were enrolled. A baseline survey of 25 questions assessing knowledge, behavioral beliefs, and attitudes toward CRC screening was administered. Descriptive statistics and univariate analysis with chi square statistics were used to characterize and examine potential differences in knowledge, attitudes, and beliefs among Chinese, Korean, and Vietnamese subject groups. Though this study involved educational interventions tailored to groups compared to controls, this analysis includes the baseline assessment only. RESULTS 228 Chinese (51 men, 157 women), 218 Korean (74 men, 143 women), and 193 Vietnamese
Adherence to Colorectal Cancer Screening Among Culturally and Linguistically Diverse Low-Income Patients - Does Patient-Provider Language Concordance Matter? Jennifer T. Chang, Alicia Fernandez, Jennifer P. Thomas, Neda Ratanawongsa, Roxana Munoz, Yunghui Lin, Chim Lau, Hal F. Yee, John M. Inadomi Background: Screening can reduce the incidence and mortality of colorectal cancer (CRC) but despite national efforts CRC screening rates remain low, especially among racial/ethnic minority populations where cultural and language barriers are posited to impede screening efforts. Language concordant providers may be able to overcome those barriers. We used data from an observational study to investigate the impact of language barriers and language concordant providers in CRC screening. Methods: We conducted an observational study of patients in a racially and ethnically diverse urban safety-net hospital. Eligible participants were recruited by culturally and linguistically concordant research assistants, who discussed screening options, explained how to perform fecal occult blood testing (FOBT), answered
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AGA Abstracts
AGA Abstracts
questions regarding preparation and conduct of colonoscopy, and facilitated transportation after colonoscopy. Participants were followed longitudinally from 3/2007-10/2009 for CRC screening completion. Adherence was defined as either FOBT or colonoscopy completion within 1 year. Limited English proficiency (LEP) patients' preferred-language was obtained via patient interview. Primary care provider's language skills were obtained from administrative records. Results: 997 patients were enrolled (34% Latino, 30% Asian, 18% black, 15% white, and 3% other). 44% of participants had LEP: preferred language was Spanish in 26% and Chinese (either Cantonese or Mandarin) in 18%. Among the 199 providers, 47% were bilingual in Spanish, 9% were bilingual in Chinese, 31% were monolingual English speakers, and 13% language skills were unknown. Adherence to CRC screening was 57% among English speakers compared with 78% in LEP Asians (OR 2.72, CI 1.82-4.08) and 73% in LEP Latinos (OR 2.12, CI 1.52-2.95). 46% of LEP participants had a language concordant provider (70% among Spanish-speakers; 10% among Chinese-speakers). Adherence rates were no different for LEP patients with language concordant providers compared to those LEP patients with language non-concordant providers, either overall: OR 0.82, CI 0.511.31, or stratified by language - Spanish: OR 0.96, CI 0.82-1.21; Chinese: OR 0.73, CI 0.24-2.19. Conclusion: In this safety net population where cancer screening options were discussed with and facilitated by culturally and linguistically concordant research assistants, patients with LEP had high rates of CRC screening that surpassed those of English speakers. Language concordance between patient and provider was not associated with screening adherence among LEP patients. Although not tested in this study, the higher than expected rates of screening adherence in LEP participants suggest that culturally and linguistically concordant patient navigators may increase adherence to CRC screening among non-English speaking populations.
87 Insurance Coverage for Screening Colonoscopy at Age 45 for African Americans: Low Adherence to Guidelines in States With Large African American Populations Lance T. Uradomo, Andrew Mener, Marie L. Borum Purpose: African Americans (AA) are at increased risk of colorectal cancer. The American College of Gastroenterology (ACG) Colorectal Cancer Screening Guidelines recommend that African Americans initiate screening at age 45 rather than 50. This study investigates whether insurers have adjusted screening coverage to reflect the new guidelines. The study also explores the ease of access to online information regarding coverage. Methods: Insurance companies were selected from the four US states with the largest AA populations: New York (NY), Texas (TX), Georgia (GA), Florida (FL), as well as the District of Columbia (DC), which has the highest percentage of AA. Companies were selected based on lists from each state's Insurance Commissioner. Those operating in multiple states were counted separately in each state. Companies that only offer Medicare Advantage Plans or do not market to individuals were excluded. Each company's website was accessed by a study co-author and 30 minutes was allocated to identify coverage policies. If unsuccessful, additional time was used to search the terms “colonoscopy,” “colorectal,” “screening,” and “preventive,” using the website's search field and then Google's “advanced search” of the website. The first 2 pages of results from each search were explored. Educational materials recommending screening were not assumed to be evidence of coverage, while a posted company guideline was. Proportions were compared with Fisher exact and chi-square tests. Results: Sixty companies were included. Specific statements or policies indicating coverage for AA at age 45 were found for 10 (16.7%). One additional company listed “special consideration” for AA without details. Coverage for AA at age 45 was found in 3 of 13 (23%) in NY, 2 of 13 (15.4%) in TX, 2 of 10 (20%) in GA, 1 of 18 (5.6%) in FL, and 2 of 6 (33.3%) in DC. Coverage at age 50 was found in 30 companies (50%) while 2 (3.3%) did not specify age. Information was found by surfing the main webpage in 14 cases (23.3%). The website search field found the data in 22 (38.3%) cases, while an advanced search identified 12 (20%) policies. No information was found in 17 cases (28.3%). There were no statistically significant differences in the coverage or the ease of finding information between states. Conclusion: Even in states with the largest African American populations, most insurers have not adopted the new ACG guideline. Coverage information was rarely easily accessible on the insurers' websites. Searches using multiple terms were required, and frequently the website's search engine had to be supplemented by an advanced search. The difficulty in finding the information may hinder average consumers in making informed decisions when choosing an insurer. 88 Differences in Knowledge, Attitudes, Beliefs, and Perceived Risks Regarding Colorectal Cancer Screening Among Chinese, Korean, and Vietnamese SubGroups T Domi Le, Patricia A. Carney, Frances Lee-Lin, Holden Leung, Christine Lau, Motomi Mori, Zunqiu Chen, David A. Lieberman
*Adjusted for age, education, and marital status 81
BACKGROUND Colorectal cancer (CRC) screening in average-risk asymptomatic populations has been shown to reduce mortality from CRC. CRC screening rates among Asian Americans, a rapidly growing population in the United States, remain lower than that of Caucasians. Reasons for this disparity are unclear and may include lack of knowledge, language barriers, and cultural beliefs that do not promote screening. Asian Americans include sub-populations with diverse cultural backgrounds that may influence beliefs about CRC screening. Interventions that target Asians may not be effective if they do not adequately address these barriers. This study aimed to assess differences in knowledge, attitudes, and beliefs on CRC screening among Chinese, Korean, and Vietnamese groups. METHODS 639 Asian Americans met inclusion criteria and were enrolled. A baseline survey of 25 questions assessing knowledge, behavioral beliefs, and attitudes toward CRC screening was administered. Descriptive statistics and univariate analysis with chi square statistics were used to characterize and examine potential differences in knowledge, attitudes, and beliefs among Chinese, Korean, and Vietnamese subject groups. Though this study involved educational interventions tailored to groups compared to controls, this analysis includes the baseline assessment only. RESULTS 228 Chinese (51 men, 157 women), 218 Korean (74 men, 143 women), and 193 Vietnamese
Adherence to Colorectal Cancer Screening Among Culturally and Linguistically Diverse Low-Income Patients - Does Patient-Provider Language Concordance Matter? Jennifer T. Chang, Alicia Fernandez, Jennifer P. Thomas, Neda Ratanawongsa, Roxana Munoz, Yunghui Lin, Chim Lau, Hal F. Yee, John M. Inadomi Background: Screening can reduce the incidence and mortality of colorectal cancer (CRC) but despite national efforts CRC screening rates remain low, especially among racial/ethnic minority populations where cultural and language barriers are posited to impede screening efforts. Language concordant providers may be able to overcome those barriers. We used data from an observational study to investigate the impact of language barriers and language concordant providers in CRC screening. Methods: We conducted an observational study of patients in a racially and ethnically diverse urban safety-net hospital. Eligible participants were recruited by culturally and linguistically concordant research assistants, who discussed screening options, explained how to perform fecal occult blood testing (FOBT), answered
S-21
AGA Abstracts
AGA Abstracts
questions regarding preparation and conduct of colonoscopy, and facilitated transportation after colonoscopy. Participants were followed longitudinally from 3/2007-10/2009 for CRC screening completion. Adherence was defined as either FOBT or colonoscopy completion within 1 year. Limited English proficiency (LEP) patients' preferred-language was obtained via patient interview. Primary care provider's language skills were obtained from administrative records. Results: 997 patients were enrolled (34% Latino, 30% Asian, 18% black, 15% white, and 3% other). 44% of participants had LEP: preferred language was Spanish in 26% and Chinese (either Cantonese or Mandarin) in 18%. Among the 199 providers, 47% were bilingual in Spanish, 9% were bilingual in Chinese, 31% were monolingual English speakers, and 13% language skills were unknown. Adherence to CRC screening was 57% among English speakers compared with 78% in LEP Asians (OR 2.72, CI 1.82-4.08) and 73% in LEP Latinos (OR 2.12, CI 1.52-2.95). 46% of LEP participants had a language concordant provider (70% among Spanish-speakers; 10% among Chinese-speakers). Adherence rates were no different for LEP patients with language concordant providers compared to those LEP patients with language non-concordant providers, either overall: OR 0.82, CI 0.511.31, or stratified by language - Spanish: OR 0.96, CI 0.82-1.21; Chinese: OR 0.73, CI 0.24-2.19. Conclusion: In this safety net population where cancer screening options were discussed with and facilitated by culturally and linguistically concordant research assistants, patients with LEP had high rates of CRC screening that surpassed those of English speakers. Language concordance between patient and provider was not associated with screening adherence among LEP patients. Although not tested in this study, the higher than expected rates of screening adherence in LEP participants suggest that culturally and linguistically concordant patient navigators may increase adherence to CRC screening among non-English speaking populations.