Heather Fagan

Background: Factors affecting colorectal cancer (CRC) screening decision stage (SDS) (i.e., decided against or never heard of (DA/NHO), not considering or undecided (NCU), decided to do (DTD), screened) are not well-documented. We seek to address this literature gap. Methods: Primary care patients ages 50-79 reported sociodemographic background, CRC screening perceptions, and SDS at baseline. Respondents were randomized to usual care, a standard intervention (mailed screening kit), or tailored navigation intervention (TNI) (mailed screening kit and telephone contact). At navigation, TNI participants reported current SDS and primary reason for SDS. Reasons were categorized using triangulation and classified either as a barrier or facilitator. Categories included: worry about CRC risk, belief in screening efficacy, perceived screening convenience, concern about screening procedure, social support, and cost. We analyzed associations between reported barriers versus facilitators and SDS...

The primary purpose of this study is to understand primary care practices' perceived constraints to engaging in research from micro-, meso-, and macro-level perspectives. Past research has spotlighted various barriers and hurdles that primary care practices face when attempting to engage in research efforts; yet a majority of this research has focused exclusively on micro- (physician-specific) and meso-level (practice-specific) factors. Minimal attention has been paid to the context - the more macro-level issues such as how these barriers relate to primary care practices' role within the dominant payment/reimbursement model of U.S. health-care system. Semi-structured focus groups were conducted in five U.S. practices, all owned by an independent academic medical center. Each had participated in at least one research study but were not part of a practice-based research network or affiliated with a medical school. Data were analyzed using NVIVO-9 by using a multistep coding process. Findings The perceived constraints offered by the participants echoed those featured in previous studies. Secondary analyses of the interconnected nature of these factors highlighted a valuable and sensitive 'Flow' that is evident at the individual, interaction, and organizational levels of primary care practice. Engaging in research appears to pose a significant threat to the outcomes of Flow (i.e., revenue, patient health outcomes, and the overall well-being of the practice). It is posited that the risk of not meeting expected productivity-based outcomes, which appear to be dictated by current dominant reimbursement models, frames the overall process of research-related decision making in primary care. Within the funding/reimbursement models of the US health-care system, engaging in research does not appear to be advantageous for primary care practices.

Colorectal cancer (CRC) screening is underutilized. Effective methods to increase screening use are needed. This study sought to determine the impact of tailored navigation on CRC screening in primary care. The study included 154 primary care practice patients who were 50 or more years of age, were eligible for CRC screening, and had an office visit within 2 years before study initiation. Baseline telephone survey data were collected on participant sociodemographic characteristics, psychosocial factors, and screening test [fecal occult blood test (FOBT) or colonoscopy] decision stage. By comparing decision stage data, we identified that test with the highest decision stage (ie, preferred screening test). Participants who preferred FOBT were sent an FOBT kit and a reminder. Those preferring colonoscopy were sent colonoscopy instructions. After this mailing, a study patient navigator made a telephone call to guide participants towards screening. Six-month end point survey and medical records data were obtained. Univariable and multivariable analyses were performed to identify predictors of screening and of change in preferred screening test decision stage. At end point, 63 (41%) study participants had screened. From baseline to end point, overall screening preference increased for 75 (63%) participants. Age and perceived salience and coherence (ie, screening is important and sensible) were positive, significant predictors of screening use (P = 0.02 and P = 0.05, respectively); while only age predicted change in overall screening preference (P = 0.03). Study participant screening use and preference increased. Age and attitudes predicted outcomes. Randomized trials are needed to determine intervention impact at the population level.

This randomized, controlled trial assessed the impact of a tailored navigation intervention versus a standard mailed intervention on colorectal cancer screening adherence and screening decision stage (SDS). Primary care patients (n = 945) were surveyed and randomized to a Tailored Navigation Intervention (TNI) Group (n = 312), Standard Intervention (SI) Group (n = 316), or usual care CONTROL GROUP (n = 317). TNI Group participants were sent colonoscopy instructions and/or stool blood tests according to reported test preference, and received a navigation call. The SI Group was sent both colonoscopy instructions and stool blood tests. Multivariable analyses assessed intervention impact on adherence and change in SDS at 6 months. The primary outcome, screening adherence (TNI Group: 38%, SI Group: 33%, 12%), was higher for intervention recipients than controls (P = 0.001 and P = 0.001, respectively), but the two intervention groups did not differ significantly (P = 0.201). Positive SDS change (TNI Group: +45%, SI Group: +37%, and +23%) was significantly greater among intervention recipients than controls (P = 0.001 and P = 0.001, respectively), and the intervention group difference approached significance (P = 0.053). Secondary analyses indicate that tailored navigation boosted preferred test use, and suggest that intervention impact on adherence and SDS was attenuated by limited access to screening options. Both interventions had significant, positive effects on outcomes compared with usual care. TNI versus SI impact had a modest positive impact on adherence and a pronounced effect on SDS. Mailed screening tests can boost adherence. Research is needed to determine how preference, access, and navigation affect screening outcomes.