Implementation and Evaluation of a Large Community-Based Colorectal Cancer Screening Program.

CONTEXT: Colorectal cancer (CRC) screening can significantly reduce incidence and mortality; however, screening rates are suboptimal. The lowest rates are among those with no usual source of care and the uninsured. OBJECTIVE: We describe the implementation and evaluation of a community-based CRC screening program from 2012 to 2015 designed to increase screening within a predominantly Hispanic US-Mexico border population. METHODS: The multicomponent, evidence-based program provided in-person, bilingual, culturally tailored health education facilitated by community health workers, no-cost primarily stool-based testing and diagnostic colonoscopy, and navigation. We recruited uninsured individuals due for CRC screening from clinics and community sites. An extensive qualitative and quantitative program process and outcome evaluation was conducted. RESULTS: In total, 20 118 individuals were approached, 8361 were eligible for screening; 74.8% completed screening and 74.6% completed diagnostic testing; 14 cancers were diagnosed. The mean age of participants was 56.8 years, and the majority were Hispanic, female, and of low socioeconomic status. The process evaluation gathered information that enabled effective program implementation and demonstrated effective staff training, compliance with processes, and high patient satisfaction. CONCLUSIONS: This program used a population-based approach focusing on uninsured individuals and proved successful at achieving high fecal immunochemical test kit return rates and colonoscopy completion rates. Key factors related to its success included tailoring the intervention to our priority population, strong partnerships with community-based sites and clinics, expertise in clinical CRC screening, and an active community advisory board. This program can serve as a model for similar populations along the border to increase CRC screening rates among the underserved.

The Prevalence of Genital Human Papillomavirus Subtypes in a Cohort of Hispanic Women Presenting for Cervical Cancer Screening Along the US-Mexico Border.

Introduction : Hispanic women residing along the US-Mexico border have the highest cervical cancer incidence rates in the US. Genital human papillomavirus (HPV) is the major causative agent, but more information is needed about the prevalence and distribution of genital HPV subtypes in this high-risk population. Methods : A population-based cross-sectional study of uninsured Hispanic women along the US-Mexico border was conducted and participants had their cervical specimens undergo DNA extraction followed by HPV genotype testing using the Linear Assay from Roche® Diagnostics, to identify 37 genital HPV subtypes. Results : Among the 585 women aged 21-65 years, 584 self-identfied as Hispanic. Any HPV subtype prevalence was 53.2% (95% CI: 49.0%-57.3%) and of these 52% (i.e. 27.5% of the total) had single infections and 48% (i.e. 25.6% of the total) had multiple infections. High-risk HPV prevalence was 15.6% (95% CI: 24-31.3%). The mean number of subtypes among those testing positive was 2.1 (SD 1.6). The prevalence of any HPV and high-risk HPV showed a U shaped pattern with age; and prevalence of 16/18 and non-16/18 high-risk subtypes (e.g. 31, 33, 35, 39, 45, 51, 52, 58); also varied with age. Forty-one percent of high-risk HPV occurrences were of a subtype not covered by the current nonavalent HPV vaccine. Discussion : Our findings suggest a different high-risk HPV subtype pattern and age distribution among Hispanic women in the USA, which could have implications for future cervical cancer prevention strategies.

Development and pilot testing of an online case-based approach to shared decision making skills training for clinicians.

BACKGROUND: Although research suggests that patients prefer a shared decision making (SDM) experience when making healthcare decisions, clinicians do not routinely implement SDM into their practice and training programs are needed. Using a novel case-based strategy, we developed and pilot tested an online educational program to promote shared decision making (SDM) by primary care clinicians. METHODS: A three-phased approach was used: 1) development of a conceptual model of the SDM process; 2) development of an online teaching case utilizing the Design A Case (DAC) authoring template, a well-tested process used to create peer-reviewed web-based clinical cases across all levels of healthcare training; and 3) pilot testing of the case. Participants were clinician members affiliated with several primary care research networks across the United States who answered an invitation email. The case used prostate cancer screening as the clinical context and was delivered online. Post-intervention ratings of clinicians' general knowledge of SDM, knowledge of specific SDM steps, confidence in and intention to perform SDM steps were also collected online. RESULTS: Seventy-nine clinicians initially volunteered to participate in the study, of which 49 completed the case and provided evaluations. Forty-three clinicians (87.8%) reported the case met all the learning objectives, and 47 (95.9%) indicated the case was relevant for other equipoise decisions. Thirty-one clinicians (63.3%) accessed supplementary information via links provided in the case. After viewing the case, knowledge of SDM was high (over 90% correctly identified the steps in a SDM process). Determining a patient's preferred role in making the decision (62.5% very confident) and exploring a patient's values (65.3% very confident) about the decisions were areas where clinician confidence was lowest. More than 70% of the clinicians intended to perform SDM in the future. CONCLUSIONS: A comprehensive model of the SDM process was used to design a case-based approach to teaching SDM skills to primary care clinicians. The case was favorably rated in this pilot study. Clinician skills training for helping patients clarify their values and for assessing patients' desire for involvement in decision making remain significant challenges and should be a focus of future comparative studies.

Impact of a Culturally Tailored Diabetes Education and Empowerment Program in a Mexican American Population Along the US/Mexico Border: A Pragmatic Study.

BACKGROUND: The study purpose was to deliver a diabetes education program under real world conditions and evaluate its effect on diabetes-related clinical, self-management and psychosocial outcomes among Mexican Americans residing along the US/Mexico border. METHODS: A pragmatic study was conducted among adult patients with diabetes in three primary care clinics located along the US/Mexico border. A bilingual culturally tailored diabetes education program incorporating hands-on participatory techniques was delivered in 4 - 8 weekly group sessions. Clinical, self-management and psychosocial outcomes were evaluated pre- and post-intervention with surveys and medical record review. RESULTS: A total of 209 participants were enrolled; mean age was 58.9 years (range 23 - 94, standard deviation: 11.2); 68.4% were female; 91.1% were Hispanic. Significant improvements were observed in glycated hemoglobin (-1.1%, P < 0.001, n = 79), total cholesterol (-17.2 mg/dL, P = 0.041, n = 63), glucose self-monitoring (+1.3 times a week, P = 0.021, n = 115), exercise less than once a week (-18.2%, P < 0.001, n = 129), nutritional behavior (+2.23, P < 0.001, n = 115), knowledge (+1. 83, P < 0.001, n = 141) and diabetes-related emotional distress (-7.32, P = 0.002, n = 111). Benefits were observed with attendance rates as low as 50%. CONCLUSION: A clinic-based culturally competent diabetes education/self-management program resulted in significant improvements in outcomes among Hispanic participants. Experimentally tested culturally appropriate interventions adapted for real world situations can benefit Mexican American diabetic patients even when attendance is imperfect.

Breast Cancer Fear Among Mexican American Women in the United States.

INTRODUCTION: Fear has been described as potentially important in affecting breast cancer screening completion. Limited information is available on the prevalence and determinants of fear among Mexican American women. This study describes perceived breast cancer fear and its association with personal characteristics and screening behavior among Mexican American women. METHODS: This is a secondary analysis of data collected during the implementation of the Breast Cancer Education, Screening and NavigaTion program among eligible uninsured women in two Texas border counties. Participants completed a 26-item survey to assess eligibility, risk status, prior screening, and breast cancer fear. Descriptive statistics and multivariable analyses were used to determine associations between the fear score, personal characteristics, and mammography screening. RESULTS: In all, 1916 of 2012 eligible women completed the study. The mean age was 57.3 years, 99.2% were Hispanic, and 88% were born in Mexico; 15% had a family history of breast cancer and 14% had never had a mammogram. The mean breast cancer fear score was 25.5 (standard deviation: 10.52; range: 8-40); 54.0 % (95% confidence interval: 52.1%-56.7%) had a high fear level. In multivariable analyses, better health status (P < .001), older age (P = .039), birth in the United States (P = .020), and having a regular doctor (P = .056) were associated with lower fear scores. There was no association between breast cancer fear and mammography screening. CONCLUSION: Breast cancer fear is high and varies by personal characteristics and health status among uninsured Mexican American border-residing women due for screening, but is not associated with screening behavior. Further research is needed to clarify the effect of interventions designed to help reduce breast cancer fear among these women, including educational interventions to reduce breast cancer fear.

Relating student performance on a family medicine clerkship with completion of Web cases.

BACKGROUND AND OBJECTIVES: This study's goal was to determine if completing Web cases improved students' performance on clerkship assessments. METHODS: We compared scores on preceptor evaluations, National Board of Medical Examiners (NBME) Subject Exam, and a standardized patient (SP)-based exam using ANCOVA for students choosing to complete assigned cases versus students not completing the assignment. We controlled for prior academic performance and clerkship timing using US Medical Licensing Exam (USMLE) Step 1 scores and rotation order. RESULTS: Students completing the case assignment scored higher on the NBME subject exam and the SP-based exam. CONCLUSION: Web-based learning was associated with improved student performance on clerkship assessments.

The effects of an educational intervention for "at-risk" residents to improve their scores on the In-training Exam.

BACKGROUND AND OBJECTIVES: The American Board of Family Practice (ABFP) In-training Exam (ITE) is one of the tools used to evaluate both a resident's progress through residency and the program itself. Investigators have examined the ITE's validity and reliability and predictors of resident performance, but no published studies have reported the effects of initiatives to improve residents' performance on the ITE. This study examines the impact of an educational intervention on low-scoring residents' ITE composite scores. METHODS: Second-year residents at a university-based program were divided into two groups. The intervention group, who took the educational intervention, all had PGY-1 scores < 400 on their composite score. The control group was comprised of residents scoring > 400 on their composite score as PGY-1s. The educational intervention involved intensive group and independent study. RESULTS: In the first year of the study, there was an increase in the average composite score of 75 points in the intervention group compared to the control group. In the second year, there was an increase of 72.5 points, but these differences were not significant. CONCLUSIONS: These composite score changes are not significant, and although this educational intervention may have improved confidence among low-scoring residents, it did not clearly improve their scores on the ITE.

Self-directed learning: looking at outcomes with medical students.

BACKGROUND AND OBJECTIVES: Self-directed learning (SDL) skills are thought to be associated with lifelong learning. This study assessed the degree of readiness for SDL in third-year medical students who participated in a problem-based learning (PBL) curriculum during thefirst 2 years of medical school. METHODS: A total of 182 third-year medical students at the University of Texas Medical Branch at Galveston were given the Self-directed Learning Readiness Scale (SDLRS). RESULTS: The observed mean (235.81 [range 183-284]) for the combined group was significantly higher than the mean reported for general adult learners (214), though slightly lower than scores reported in studies of other medical students and professionals. Ratings of students by clinical preceptors correlated with SDLRS scores. CONCLUSIONS: Students in our integrated medical curriculum had scores on the SDLRS that correlated with clinical performance and probably represented a readiness for SDL.

Integrating telemedicine instruction into the curriculum: expanding student perspectives of the scope of clinical practice.

We have developed a telemedicine elective for fourth-year medical students to learn about the delivery of primary care telemedicine. The goals were to expose medical students to telemedicine as a method for delivery of primary care and to reinforce the importance of doctor-patient communication during the health-care encounter. The elective lasted four weeks. It had three components: two online introductory courses to telemedicine; site visits to near and distant telemedicine sites; and a reflective writing paper. In the first year, seven medical students out of a class of 230 chose the telemedicine elective from a list of 188 alternatives. Evaluation ratings and the students' written comments, along with end-of-course discussions, indicated that the telemedicine elective was a valuable experience. An elective in the medical school curriculum may be a useful way of providing future physicians with an understanding of telemedicine.

"Coming about!"--a faculty workshop on teaching beliefs.

BACKGROUND: The role of faculty in academic health care centers is changing rapidly. Identifying and examining personal teaching beliefs and values can help faculty members improve their performance and change the way in which they view their roles as educators. DESCRIPTION: A structured, 2-h workshop is detailed in this paper. It involves individual reflection, facilitated small group dialogue, and large group discussion. Expected outcomes of the workshop are a start on a teaching philosophy for inclusion in a faculty teaching portfolio, along with a personal metaphor for teaching. EVALUATION: This workshop has been offered nine times with both campus faculty and community preceptors. Both qualitative and quantitative measures are detailed that demonstrate its value. CONCLUSIONS: Faculty members should be provided with structured opportunities to reflect on evolving issues in medical education. This workshop on teaching beliefs is one effective way of challenging faculty to reexamine personal values.

Physician and patient influences on the rate of colorectal cancer screening in a primary care clinic.

BACKGROUND: Colorectal cancer (CRC) screening rates remain low, despite widespread recommendations. The study purpose was to ascertain whether lack of CRC screening is attributable to physicians' failure to address CRC screening or to patients' failure to comply with physician recommendation. This relationship was also examined over time. METHODS: Retrospective chart review of 400 preventive health visits. RESULTS: Physicians appropriately addressed screening 16.5% of the time during 1998-1999 and 51% of the time during 2002-2003 (P

Student perspectives on the integration of interactive Web-based cases into a family medicine clerkship.

BACKGROUND: Web-based methods are increasingly used to educate medical students; several clerkships now use Web-based cases to supplement students' clinical experiences. However, few studies have reported on students' responses to specific features of interactive Web-based cases. DESCRIPTION: We developed an online template to author Web cases and created eight cases. We evaluated the usefulness of case-based learning for students at the end of each clerkship period, using a 9-item questionnaire with a 6-point scale, written student comments on the Web cases, and student focus groups. EVALUATION: We report a 95% response rate, with 85% of students completing all 3 Web cases. Students were most enthusiastic about feedback from faculty after completing each module. They also liked the user-friendly Web design and linear format of the Web cases. CONCLUSION: Students were enthusiastic about the interactive Web-based cases and thought that the cases reinforced knowledge on common medical problems seen in the clinical setting.

Roseomonas gilardii infection: case report and review.

Roseomonas gilardii is a bacterium that has been indicated as a rare cause of human infections. The case of a patient presenting with cellulitis and bacteremia secondary to R. gilardii is described together with the clinical characteristics of infection with this organism obtained from a review of cases previously reported.