Clinical Pathway for Suicide Risk Screening in Adult Primary Care Settings: Special Recommendations.

Suicide is a serious public health concern. On average, 80% of suicide decedents had contact with primary care within 1 year of their suicide. This and other research underscore the importance of screening for suicide risk within primary care settings, and implementation of suicide risk screening is already underway in many practices. However, while primary care practices may be familiar with screening for other mental health concerns (e.g., depression), many feel uncomfortable or unprepared for suicide risk screening. To meet the increasing demand for evidence-based suicide-risk-screening guidance, we provide a clinical pathway for adult primary care practices (to include family medicine, internal medicine, women's health). The pathway was developed by experts with research, clinical expertise, and experience in suicide risk screening and primary care. We also provide detailed guidance to aid primary care practices in their decisions about how to implement the clinical pathway.

Patient education for colon cancer screening: a randomized trial of a video mailed before a physical examination.

BACKGROUND: Colorectal cancer screening is underused, and primary care clinicians are challenged to provide patient education within the constraints of busy practices. OBJECTIVE: To test the effect of an educational video, mailed to patients' homes before a physical examination, on performance of colorectal cancer screening, particularly sigmoidoscopy. DESIGN: Randomized, controlled trial. SETTING: 5 primary care practices in central Massachusetts. PARTICIPANTS: 938 patients age 50 to 74 years who were scheduled for an upcoming physical examination, had no personal history of colorectal cancer, and were eligible for lower-endoscopy screening according to current guidelines. INTERVENTION: Participants were randomly assigned to receive usual care (n = 488) or a video about colorectal cancer, the importance of early detection, and screening options (n = 450). MEASUREMENTS: Baseline and 6-month follow-up telephone assessments were conducted. A dependent variable classified screening since baseline as 1) sigmoidoscopy with or without other tests, 2) another test or test combination, or 3) no tests. RESULTS: Overall screening rates were the same in the intervention and control groups (55%). In regression modeling, intervention participants were nonsignificantly more likely to complete sigmoidoscopy alone or in combination with another test (odds ratio, 1.22 [95% CI, 0.88 to 1.70]). Intervention dose (viewing at least half of the video) was significantly related to receiving sigmoidoscopy with or without another test (odds ratio, 2.81 [CI, 1.85 to 4.26]). Recruitment records showed that at least 23% of people coming for periodic health assessments were currently screened by a lower-endoscopy procedure and therefore were not eligible. LIMITATIONS: The primary care sample studied consisted primarily of middle-class white persons who had high screening rates at baseline. The results may not be generalizable to other populations. The trial was conducted during a period of increased health insurance coverage for lower-endoscopy procedures and public media attention to colon cancer screening. CONCLUSIONS: A mailed video had no effect on the overall rate of colorectal cancer screening and only modestly improved sigmoidoscopy screening rates among patients in primary care practices.

Screening for colorectal cancer on the front line.

OBJECTIVE: The aim of this study was to assess knowledge, beliefs, and practices of primary care clinicians regarding colorectal cancer screening. METHODS: We surveyed 77 primary care providers in six clinics in central Massachusetts to evaluate several factors related to colorectal cancer screening. RESULTS: Most agreed with guidelines for fecal occult blood test (97%) and sigmoidoscopy (87%), which were reported commonly as usual practice. Although the majority (86%) recommended colonoscopy as a colorectal cancer screening test, it was infrequently reported as usual practice. Also, 36% considered barium enema a colorectal cancer screening option, and it was rarely reported as usual practice. Despite lack of evidence supporting effectiveness, digital rectal examinations and in-office fecal occult blood test were commonly reported as usual practice. However, these were usually reported in combination with a guideline-endorsed testing option. Although only 10% reported that fecal occult blood test/home was frequently refused, 60% reported sigmoidoscopy was. Frequently cited patient barriers to sigmoidoscopy compliance included fear the procedure would hurt and that patients assume symptoms occur if there is a problem. Perceptions of health systems barriers to sigmoidoscopy were less strong. CONCLUSIONS: Most providers recommended guideline-endorsed colorectal cancer screening. However, patient refusal for sigmoidoscopy was common. Results indicate that multiple levels of intervention, including patient and provider education and systems strategies, may help increase prevalence.