VCU Department of Family Medicine

Colonoscopy screening frequency

Date: November 2006-December 2007
Principal investigators: Alexander H. Krist, M.D., M.P.H., Resa M. Jones, Ph.D.
Funding: Unfunded

Question

To what extent are endoscopists’ recommendations on repeat colonoscopy concordant with the most current (2006) guidelines on post-polypectomy surveillance and screening?

Background

Colonoscopy possesses the highest sensitivity of available screening tests for colorectal cancer and polyps, but it also carries risks. Appropriate intervals for repeating colonoscopy are important to ensure that the benefits of screening and surveillance are not offset by harms. The study objective was to examine whether endoscopists’ recommendations for repeat colonoscopy, as communicated to primary care clinicians after the procedure, adhered to published guidelines.

Method

Analysts abstracted medical records at ten primary care practices in Virginia and Maryland in 2006. The records of a random sample of men and women (300 per practice) aged 50 to 70 years were reviewed. The sample included patients who had a colonoscopy and a written report from an endoscopist, and who lacked designated risk factors. The main outcome was concordance between endoscopists’ recommendations and published guidelines regarding repeat colonoscopy.

Results

Of 3000 charts reviewed, 1,282 (42.7 percent) included records of a colonoscopy and 1,021 (34 percent) included an endoscopist’s report. In 64.9 percent of communications, the endoscopist specified when retesting should occur. Recommendations were consistent with contemporaneous guidelines in only 39.2 percent of cases and with current guidelines in 36.7 percent of cases. The adjusted mean number of years in which repeat colonoscopy was recommended was 7.8 years following normal colonoscopy and 5.8 years and 4.4 years, respectively, when hyperplastic polyps or one to two small adenomatous polyps were found.

Conclusion

Endoscopists often recommended repeat colonoscopy at shorter intervals than are advised either by current guidelines or by guidelines in effect at the time of the procedure. Endoscopists’ communications to primary care clinicians often lacked contextual information that might explain these discrepancies. Unless appropriate caveats apply, adhering to endoscopists’ recommendations may incur unnecessary harms and costs.

Publications

Presentations

Promoting healthy behaviors in primary care research networks

Date: July 1, 2003-Oct. 31, 2004
Principal investigator: Steven H. Woolf, M.D., M.P.H.
Funding: Robert Wood Johnson Foundation

Hypothesis

Primary care patients who visit a specially designed, practice-sponsored Web site will exhibit a greater shift toward readiness to change behaviors in relation to diet, physical activity, smoking and problem drinking than occurs under usual care.

Aims

To test the effectiveness and feasibility of using a practice-sponsored Web site to help primary care clinicians promote healthy diet, physical activity, tobacco cessation and healthy alcohol use among their patients.

Description

This 16-month study employed a pre-post design to study effectiveness and feasibility in four intervention and two control practices in Northern Virginia. The aim of the Web site was to link patients with the information, resources and services that were most likely to facilitate behavior change but that were difficult to identify or arrange at the conventional office visit, or at other times when patients needed them. The Web site hosted a comprehensive array of resources regarding healthy behaviors.

Conclusion

The intervention increased the rate at which patients were referred for intensive behavioral counseling compared to current practice norms. Given the evidence that intensive counseling is more effective in promoting behavior change, implementing eLinkS could have substantial public health benefits.

Collaboration between clinicians and community resources presents a “win-win” scenario for patients, clinicians and community programs. Patients obtain more intensive assistance, while clinicians welcome an easy means to connect patients with the help they need. Community programs, which often struggle to attract clients through media and advertising, appreciate the influx of referrals from the medical community.

This formula has implications that extend beyond behavioral counseling. A system like eLinkS that facilitates systematic screening and referrals could, with some modification, help clinicians arrange screening tests and chronic disease management. Clinician-community collaboration has long been advocated for these purposes, but applying modern technology to make collaboration easy holds considerable promise.

Publications

Presentations

Does checking smoking status as a vital sign increase physician counseling? A practice-level randomized controlled trial

Dates: 1998-2005
Principal investigator: Stephen F. Rothemich, M.D.
Funding: Robert Wood Johnson Foundation’s Generalist Physician Faculty Scholars Program

Purpose

Guidelines encourage primary care clinicians to document smoking status when obtaining vital signs, but whether this promotes cessation counseling is unclear. We examined whether the vital sign intervention influenced patient-reported frequency and intensity of tobacco-cessation counseling.

Methods

Cluster-randomized controlled trial in VACORN. Nursing staffs at intervention practices were instructed to assess the tobacco status of every adult patient and record it with the traditional vital signs. Control practices used no systematic tobacco screening or identification system. Outcomes were the proportion of smokers reporting clinician counseling of any kind and the frequency of two counseling subcomponents — simple quit advice and more intensive discussion.

Results

A total of 6,729 adult patients, including 1,149 smokers, at 18 primary care practices completed exit surveys during a six-month comparison period. Among 561 smokers at intervention practices, 61.9 percent reported receiving any counseling compared with 53.4 percent of the 588 smokers at control practices (difference 8.6 percent, p=0.04). The effect was largely restricted to simple advice, which was reported by 59.9 percent of intervention patients and 51.5 percent of control patients (p=0.04). There was no significant increase in more extensive discussion: 32.5 percent and 29.3 percent at intervention and control practices respectively (p=0.18).

Conclusions

The vital sign intervention promotes tobacco counseling at primary care practices through a modest increase in simple advice to quit. Implemented as a single intervention, it does not appear to increase intensive counseling.

Publications

Presentations

Tobacco use in primary care practice populations: A pilot cohort study

Date: 2003-04
Principal investigators: Stephen F. Rothemich, M.D., M.S., Diane B. Wilson, Ed.D.
Funding: Massey Cancer Center, Virginia Commonwealth University

Hypothesis

1. The proposed postal methodology for longitudinal follow-up of prior in-office survey participants will result in at least a 50 percent participation rate.
2. The resulting longitudinal data will be of sufficient volume and quality to estimate tobacco cessation, initiation and relapse rates in practice populations.
3. The resulting longitudinal data will be of sufficient volume and quality to perform additional exploratory data analyses as described in the second aim.

Aims

1. Demonstrate the feasibility of using a postal survey methodology to collect longitudinal patient-provided data in multiple primary care practices on health behaviors, functional health status, demographics and receipt of evidence-based screening tests for subsequent use in larger, longer cohort studies.
2. Using longitudinal data collected from patient responses to a mailed survey, linked to participants’ administrative data and previous in-office survey responses, perform statistical analyses to examine tobacco cessation and relapse in this population, including associations with demographics, comorbidities, health status and other health behaviors, such as diet and exercise.

Description

Sequential mailing method of a survey to more than 2,500 patients in two practices who had completed a similar in-office survey at least 12 months previously. The initial survey mailing included a cover letter of invitation, consent information, a $2 participation incentive and a postage-paid pre-addressed return envelope. One week after the first mailing a reminder postcard was sent to each recipient of the initial mailing. A second survey mailing was sent to non-respondents at three weeks past the initial mailing.

Outcomes

The response rate was 56 percent, which was deemed successful in this setting. The methods used in this sequential mailing have served as the model for other VACORN studies that involved a postal survey. Analysis of respondents’ changes in responses compared to their previous in-office survey has not yet been completed.

A preventive care Web site to promote primary and secondary prevention of cancers

Date: April 2005-March 2006
Principal investigator: Alexander H. Krist, M.D., M.P.H.
Funding: Massey Cancer Center, Virginia Commonwealth University

Hypothesis

This pilot study seeks to evaluate whether patients and physicians will use a cancer preventive care Web site prior to a health maintenance examination. Ultimately the Web site has the potential to improve the delivery of cancer preventive services.

Aims

1. To develop a cancer preventive care Web site for patients that would effectively integrate multiple tools proven to improve primary and secondary cancer prevention, such as tailored health messages, reminder systems, decision aids and risk-assessment instruments.
2. To evaluate perceived value and use of such a Web site by primary care clinicians and patients.

Description

A cancer preventive care Web site, www.MyPreventiveCare.net, was developed. More than 500 patients presenting for a health maintenance examination were asked to use the Web site prior to their next office visit. Participants were surveyed about their experience.

Outcomes

Of the patients instructed to use the Web site prior to their office visit, 78 percent did so. Among patients and physicians who used the Web site, there was satisfaction with the information provided. Helpful information about desired Web site format and content was learned and will be used in redesigning future versions of MyPreventiveCare.

Presentations

Primary care practice-based research networks: Network defining data for VACORN

Dates: February-August 2002
Principal investigator: Stephen F. Rothemich, M.D., M.S.
Funding: Agency for Healthcare Research and Quality

Objectives

This study was done in parallel with 18 other practice-based research networks across the country as part of the AHRQ Primary Care Practice-Based Research Network Initiative.

VACORN’s objectives included

1. Providing benchmark data to practices for visit data not otherwise available in VACORN’s core data set, such as reason for encounter, health counseling/education services, medications and visit duration.
2. Establishing an initial data set of VACORN provider and practice characteristics for the core data set.
3. Making it possible to compare VACORN to other PBRNs and determine in what ways VACORN is similar or unique both for planning collaborative studies with other PBRNs and for speaking to the generalizability of VACORN research findings through comparison with national data.
4. For data elements that do overlap with those collected through other means in VACORN, such as patient self-reported race/ethnicity and demographic, insurance status, diagnoses and procedural data from administrative data, providing an opportunity for making comparisons between these two data sources at the individual level as well as at the aggregate level as means of characterizing practices.
5. Helping us focus on classification and translation of data we currently obtain, such as the practice’s designation of primary insurance type for visits, but had yet to organize in ways that allow us to make comparisons between practices or collapse the data into meaningful categories.

Description

Of 93 clinicians in 12 VACORN practices, 100 percent were invited to participate in the study, as well as 29 providers. They were asked to complete a survey form about themselves and, if willing, to record 30 encounters on a different survey form. The survey was developed in collaboration with the other 18 networks in the study, with many data elements based upon the content of the National Ambulatory Medical Care Survey from the Center for Health Statistics.

Outcomes

1. VACORN contributed to AHRQ’s national inventory of practice-based research networks.
2. Elements from the practice and provider surveys were incorporated into VACORN’s yearly inventory.

Publications