ICU Admission Source as a Predictor of Mortality for Patients With Sepsis.

PURPOSE: Sepsis is the leading noncardiac cause of intensive care unit (ICU) death. Pre-ICU admission site may be associated with mortality of ICU patients with sepsis. This study quantifies mortality differences among patients with sepsis admitted to an ICU from a hospital ward, emergency department (ED), or an operating room (OR). METHODS: We conducted a retrospective cohort study of 1762 adults with sepsis using ICU record data obtained from a clinical database of an academic medical center. Survival analysis provided crude and adjusted hazard rate ratio (HRR) estimates comparing hospital mortality among patients from hospital wards, EDs, and ORs, adjusted for age, sex, and severity of illness. RESULTS: Mortality of patients with sepsis differed based on the pre-ICU admission site. Compared to patients admitted from an ED, patients admitted from hospital wards had higher mortality (HRR: 1.35; 95% confidence interval [CI]: 1.09-1.68) and those admitted from an OR had lower mortality (HRR: 0.37; 95% CI: 0.23-0.58). CONCLUSION: Patients with sepsis admitted to an ICU from a hospital ward experienced greater mortality than patients with sepsis admitted to an ICU from an ED. These findings indicate that there may be systematic differences in the selection of patient care locations, recognition, and management of patients with sepsis that warrant further investigation.

Persuasive Interventions for Controversial Cancer Screening Recommendations: Testing a Novel Approach to Help Patients Make Evidence-Based Decisions.

PURPOSE: We wanted to evaluate novel decision aids designed to help patients trust and accept the controversial, evidence-based, US Preventive Services Task Force recommendations about prostate cancer screening (from 2012) and mammography screening for women aged 40 to 49 years (from 2009). METHODS: We created recorded vignettes of physician-patient discussions about prostate cancer screening and mammography, accompanied by illustrative slides, based on principles derived from preceding qualitative work and behavioral science literature. We conducted a randomized crossover study with repeated measures with 27 men aged 50 to 74 years and 35 women aged 40 to 49 years. All participants saw a video intervention and a more traditional, paper-based decision aid intervention in random order. At entry and after seeing each intervention, they were surveyed about screening intentions, perceptions of benefits and harm, and decisional conflict. RESULTS: Changes in screening intentions were analyzed without regard to order of intervention after an initial analyses showed no evidence of an order effect. At baseline, 69% of men and 86% of women reported wanting screening, with 31% and 6%, respectively, unsure. Mean change on a 3-point, yes, unsure, no scale was -0.93 (P = <.001) for men and -0.50 (P = <.001) for women after seeing the video interventions vs 0.0 and -0.06 (P = .75) after seeing the print interventions. At the study end, 33% of men and 49% of women wanted screening, and 11% and 20%, respectively, were unsure. CONCLUSIONS: Our novel, persuasive video interventions significantly changed the screening intentions of substantial proportions of viewers. Our approach needs further testing but may provide a model for helping patients to consider and accept evidence-based, counterintuitive recommendations.

Does Infection Site Matter? A Systematic Review of Infection Site Mortality in Sepsis.

PURPOSE: Sepsis treatment protocols emphasize source control with empiric antibiotics and fluid resuscitation. Previous reviews have examined the impact of infection site and specific pathogens on mortality from sepsis; however, no recent review has addressed the infection site. This review focuses on the impact of infection site on hospital mortality among patients with sepsis. METHODS: The PubMed database was searched for articles from 2001 to 2014. Studies were eligible if they included (1) one or more statistical models with hospital mortality as the outcome and considered infection site for inclusion in the model and (2) adult patients with sepsis, severe sepsis, or septic shock. Data abstracted included stage of sepsis, infection site, and raw and adjusted effect estimates. Nineteen studies were included. Infection sites most studied included respiratory (n = 19), abdominal (n = 19), genitourinary (n = 18), and skin and soft tissue infections (n = 11). Several studies found a statistically significant lower mortality risk for genitourinary infections on hospital mortality when compared to respiratory infections. CONCLUSION: Based on studies included in this review, the impact of infection site in patients with sepsis on hospital mortality could not be reliably estimated. Misclassification among infections and disease states remains a serious possibility in studies on this topic.

Digital Health Information Disparities in Older Adults: a Mixed Methods Study.

Important health information including disease prevention and chronic disease self-management is increasingly packaged for digital use. The purpose of this sequential explanatory mixed methods study was to describe the extent of computer ownership, Internet access, and digital health information use in an ethnically diverse sample of older adults, comparing ownership, access, and use of digital health information (DHI) across ethnic groups and identifying the factors associated with them quantitatively. Significant differences in computer ownership, Internet access, and DHI use were found across ethnic groups (African American, Afro-Caribbean, Hispanic American, and European American). Logistic regression identified older age, less education, lower income, and minority group membership as significant predictors of limited DHI use. Older African Americans were one-fifth as likely to own a computer than were European Americans; Hispanic Americans were one-half as likely to have access to the Internet. We then conducted a series of focus groups which highlighted differences across ethnic groups. Participants in the African American/Afro-Caribbean group expressed frustration with lack of access to DHI but appreciation for alternative sources of information. Hispanic Americans critiqued information received from providers and drug inserts, some suggesting that a positive attitude and trust in God also contributed to getting well. European American participants evaluated various DHI websites, looking to providers for help in applying information to their personal situation. As the development and use of DHI continue, parallel efforts to increase access to DHI among economically disadvantaged and minority older adults are critical to prevent further disfranchisement.

Design and methods for a randomized clinical trial comparing three outreach efforts to improve screening mammography adherence.

BACKGROUND: Despite the demonstrated need to increase screening mammography utilization and strong evidence that mail and telephone outreach to women can increase screening, most managed care organizations have not adopted comprehensive outreach programs. The uncertainty about optimum strategies and cost effectiveness have retarded widespread acceptance. While 70% of women report getting a mammogram within the prior 2 years, repeat mammography rates are less than 50%. This 5-year study is conducted though a Central Massachusetts healthcare plan and affiliated clinic. All women have adequate health insurance to cover the test. METHODS/DESIGN: This randomized study compares 3 arms: reminder letter alone; reminder letter plus reminder call; reminder letter plus a second reminder and booklet plus a counselor call. All calls provide women with the opportunity to schedule a mammogram in a reasonable time. The invention period will span 4 years and include repeat attempts. The counselor arm is designed to educate, motivate and counsel women in an effort to alleviate PCP burden.All women who have been in the healthcare plan for 24 months and who have a current primary care provider (PCP) and who are aged 51-84 are randomized to 1 of 3 arms. Interventions are limited to women who become ≥ 18 months from a prior mammogram. Women and their physicians may opt out of the intervention study.Measurement of completed mammograms will use plan billing records and clinic electronic records. The primary outcome is the proportion of women continuously enrolled for ≥ 24 months who have had ≥ 1 mammogram in the last 24 months. Secondary outcomes include the number of women who need repeat interventions. The cost effectiveness analysis will measure all costs from the provider perspective. DISCUSSION: So far, 18,509 women aged 51-84 have been enrolled into our tracking database and were randomized into one of three arms. At baseline, 5,223 women were eligible for an intervention. We anticipate that the outcome will provide firm data about the maximal effectiveness as well as the cost effectiveness of the interventions both for increasing the mammography rate and the repeat mammography rate. TRIAL REGISTRATION: http://clinicaltrials.gov/NCT01332032.

Design of a handheld electronic pain, treatment and activity diary.

Effective tools for recording and analyzing data on patients' pain experience, use of pain treatments, and physical function are needed to improve communication between providers and patients with noncancer chronic pain. A handheld electronic diary (HED) that can be used throughout the day may provide more useful and accurate information about pain, treatments, and function than available paper and on-line diaries that are designed to be used once daily, weekly or less often. Based on user-specified requirements we designed and built a prototype HED with 7 modules. Diary queries are followed by multiple choice responses customized to the patients' expected responses. Usability testing confirmed user comprehension and acceptability of the queries, response sets, and interface.

"They don't want anything to do with you": patient views of primary care management of chronic pain.

OBJECTIVE: Chronic pain is one of the most frequent complaints of patients in primary care, yet both patients and providers report low satisfaction with chronic pain care. This study was designed to explore the views held by a diverse sample of patients with chronic pain complaints about their care experiences to identify ways to improve care. DESIGN: Qualitative analysis of 17 patient focus groups (size 3-7 participants). Groups used structured questions and were tape recorded, transcribed, and coded using qualitative software. Eleven groups were conducted in English, six groups in Spanish. PATIENTS: Convenience sample of 72 adult patients (68% female, 44% Latino, mean age=48.1 years) recruited from four diverse primary care practices in Central Massachusetts. RESULTS: Across all 17 groups, and all gender, ethnicity, and age groups, most patients reported suboptimal interactions with their providers when seeking care for chronic pain. Subjects acknowledged feeling disrespected and distrusted, suspected of drug-seeking, and having their symptoms dismissed as trivial and/or not warranting medical care. Patients reported more satisfaction when they felt a provider listened to them, trusted them, was accessible to address pain concerns between visits, and used patient-centered approaches to establish goals and treatment plans. Patients also recommended some management techniques related to the chronic disease management model to improve pain care. CONCLUSIONS: Implementing patient-centered approaches in caring for individuals with chronic pain and using principles drawn from the chronic disease management model to improve care systems may improve both patient and provider satisfaction with chronic pain care.

Comparing Telephone Counseling With Reminding to Promote On-Time Repeated Mammography: A Randomized Trial in a Cohort With 4 Years Follow-Up.

Background. Long-term continuous adherence to biennial screening mammograms as guidelines recommend remains low. Limited evidence suggests that reminder calls may increase short-term adherence as much as telephone counseling, but research is needed comparing the long-term effects of these two approaches. Purpose. To compare the impacts of two telephone outreach interventions and mailed reminders on 4-year continuous mammography adherence. Method. A cohort of 3,215 women, age 50 to 81 years, was selected from 30,160 women from a 4-year randomized trial of three interventions to promote biennial mammography: reminder letter only (LO), letter plus reminder call (RC), and two letters plus educational material and a counseling call (CC). Women selected remained eligible for the trial all 4 years and received annual interventions as needed. The proportion with a mammogram in the last 24 months was determined at baseline and four annual time points. Results. Continuous adherence at all four time points was higher in the RC (78.8%) and CC arms (78.8%) than in the LO arm (75.1%; p < .001). Multivariable analysis confirmed this finding: CC (odds ratio = 1.27; 95% confidence interval = [1.01, 1.61]) and RC (odds ratio = 1.23; 95% confidence interval = [0.98, 1.56]). Only 27.8% of women eligible for an initial counseling call actually received counseling. Conclusions. Compared with letters alone, outreach calls can modestly increase continuous mammography adherence among insured women with consistent primary care. Telephone counseling was no more effective than a reminder call, possibly due to limited acceptance of counseling calls by women who may find them unwelcome or unnecessary.

Tools to Promote Shared Decision-Making in Lung Cancer Screening Using Low-Dose CT Scanning: A Systematic Review.

BACKGROUND: Decisions about lung cancer screening are inherently complex and create a need for methods to convey the risks and benefits of screening to patients. RESEARCH QUESTION: What kind of decision aids or tools are available to support shared decision-making for lung cancer screening? What is the current evidence for the effectiveness, acceptability, and feasibility of those tools? STUDY DESIGN AND METHODS: We conducted a systematic review of studies and searched PubMed, MEDLINE, EMBASE, Cochrane Clinical Trials Register, and ClinicalTrials.gov from inception to December 2019 for studies that evaluated the effectiveness and acceptability of tools to promote shared decision-making for patients who are considering lung cancer screening. RESULTS: After screening 2,427 records, we included one randomized control trial, two observational studies, 11 before/after studies of a decision aid or an educational tool. Fifteen distinct tools in various formats were evaluated in 14 studies. Most studies were of fair quality. Studies reported improvement in patients' knowledge of lung cancer screening (n = 9 studies), but improvements in specific areas of knowledge were inconsistent. Decisional conflict was low or reduced after the administration of the tools (n = 7 studies). The acceptability of tools was rated as "high" by patients (n = 7 studies) and physicians (n = 1 study). Low dose CT scan completion rates varied among studies (n = 6 studies). INTERPRETATION: Evidence from 14 studies suggests that some elements of existing tools for lung cancer screening may help to prepare patients for decision-making by improving knowledge and reducing decisional conflict. Such tools generally are acceptable to patients and providers. Further studies that use consistent measures and reporting methods and assess relevant decisional and clinical outcomes are needed to determine the comparative effectiveness and feasibility of implementation of these tools. CLINICAL TRIAL REGISTRATION: PROSPERO 2018 CRD4201874814.

Moving mammogram-reluctant women to screening: a pilot study.

BACKGROUND: Effective interventions are needed for women long overdue for screening mammography. PURPOSE: The purpose of this study is to pilot test an intervention for motivating overdue women to receive a mammogram. METHODS: Subjects aged 45-79 without a mammogram in > or =27 months and enrolled in study practices were identified from claims data. The intervention included a mailed, educational booklet, computer-assisted barrier-specific tailored counseling and motivational interviewing, and facilitated, short-interval mammography scheduling. RESULTS: Of 127 eligible women, 45 (35.4%) agreed to counseling and data collection. Most were > or =3 years overdue. Twenty-six (57.8%) of the counseled women got a mammogram within 12 months. Thirty-one (72.1%) of 43 counseled women moved > or =1 stage closer to screening, based on a modified Precaution Adoption Process Model. CONCLUSION: It is feasible to reach and counsel women who are long overdue for a mammogram and to advance their stage of adoption. The intervention should be formally evaluated in a prospective trial comparing it to control or to proven interventions.

A 4-year randomized trial comparing three outreach interventions to promote screening mammograms.

As population health has become a focus of health care payers and providers, interest has grown in mail, phone, and other forms of outreach for improving population rates of cancer screening. Translational research is needed to compare the effectiveness and cost of low- and high-intensity behavioral outreach interventions for promoting cancer screening. The purpose of the article is to compare the effectiveness in promoting biannual mammograms of three interventions delivered over 4 years to a primary care population with a high baseline mammography adherence of 83.3%. We randomized women aged 40-84 to reminder letter only (LO arm), letter + reminder call (RC arm), and two letters + counseling call (CC arm) involving tailored education and motivational interviewing. Mammography adherence (≥1 mammogram in the previous 24 months) at four time points was determined from insurance claims records. Over 4 years, 30,162 women were randomized. At the end of 4 years, adherence was highest in the RC arm (83.0%) compared with CC (80.8%) and LO (80.8%) arms (p = .03). Only 23.5% of women in the CC arm were reached and accepted full counseling. The incremental cost per additional mammogram for RC arm women was $30.45 over the LO arm cost. A simple reminder call can increase screening mammogram adherence even when baseline adherence is high. Some more complex behavioral interventions delivered by mail and phone as in this study may be less effective, due to limited participation of patients, a focus on ambivalence, lack of follow-up, and other factors.

Staging mammography nonadherent women: a qualitative study.

BACKGROUND: Few studies have related stages of mammography screening nonadherence with the rationale used by overdue women. METHODS: We used a grounded theory approach to obtain and analyze data from focus groups, telephone interviews, and surveys. Emergent specific themes were compared with emerging decision levels of nonadherence. Each decision level was then compared with the Precaution Adoption Process Model and the Transtheoretical Model. RESULTS: A total of 6 key themes influencing mammogram nonadherence emerged as did 6 decision levels. Variability within themes was associated with specific decision levels. The decision levels were not adequately classified by either stage model. CONCLUSIONS: Stage-based educational strategies may benefit by tailoring interventions to these 6 decision levels.

Implementation and process evaluation of three interventions to promote screening mammograms delivered for 4 years in a large primary care population.

The optimal form of outreach to promote repeated, on time screening mammograms in primary care has not been established. The purpose of this study is to assess the implementation process and process outcomes for three interventions for promoting biannual screening mammography in a randomized trial. In a large urban primary care practice over a 4-year period, we randomized women aged 40-85 and eligible for mammograms to three interventions: reminder letter only (LO), reminder letter + reminder call (RC), and reminder letter + counseling call (CC). We tracked information system development, staff training, patient and provider recruitment, reach, dose delivered and received, fidelity, and context measures. Ninety-three of 95 providers approved participation by 80% (23,999) of age-eligible patients, of whom only 207 (0.9%) opted not to receive any intervention. Of 9161 initial reminder letters mailed to women coming due or overdue for mammograms, 0.8% were undeliverable. Of women in the RC and CC arms unresponsive to the first reminder letter (n = 3982), 71.4% were called and reached, and of those, 49.1% scheduled a mammogram. Only 33.4% of women reached in the CC arm received full counseling, and women in the CC arm were less likely to schedule a mammogram than those in the RC arm. Implementing mail and telephone mammography reminders is feasible and acceptable in a large urban practice and reaches a majority of patients. Many schedule a mammogram when reached. A reminder letter followed by a simple reminder call if needed may be the optimal approach to promoting screening mammograms.

Impact of 2012 USPSTF Screening PSA Guideline Statement: Changes in Primary Care Provider Practice Patterns and Attitudes.

INTRODUCTION: Prostate specific antigen use in prostate cancer screening has undergone significant changes since the 2012 release of the USPSTF (United States Preventive Services Task Force) guideline statement. The effect on specific primary care provider practice patterns and attitudes is not well characterized. We describe the impact of the USPSTF statement on prostate cancer screening practices, attitudes and knowledge among primary care providers. METHODS: A survey composed of 25 questions was mailed electronically to approximately 350 primary care providers within a single academic health care system. Responses were recorded and could not be traced to the respondent. RESULTS: A total of 73 primary care providers (21%) responded to the survey. Of the respondents 75% reported a change in prostate specific antigen screening practices resulting from the USPSTF recommendations and 35% reported a decrease in digital rectal examination use, although the latter test is not explicitly addressed in the guideline statement. A third of respondents believe that prostate specific antigen screening has "likely had no role" in the 2-decade decline in prostate cancer mortality and 70% agree that prostate specific antigen screening may "impart more harm than good" to the patient. Despite these opinions, there was markedly greater concern for medicolegal consequences of a missed diagnosis compared to over diagnosis. CONCLUSIONS: The results of the survey, while limited to a single large academic center, show the impact of the USPSTF 2012 statement on physician attitudes and practice patterns. The results define the need for more educational opportunities for primary care providers regarding the USPSTF statement, American Urological Association guidelines and identification of patients appropriate for prostate specific antigen screening.

Primary care provider concerns about management of chronic pain in community clinic populations.

BACKGROUND: Chronic pain is a common patient complaint in primary care, yet providers and patients are often dissatisfied with treatment processes and outcomes. OBJECTIVE: To assess provider satisfaction with their training for and current management of chronic pain in community clinic settings. To identify perceived problems with delivering chronic pain treatment and issues with opioid prescribing for chronic pain. DESIGN: Mailed survey to primary care providers (PCPs) at 8 community clinics. RESULTS: Respondents (N=111) included attendings, residents, and nurse practioners (NPs)/physician assistants (PAs). They reported 37.5% of adult appointments in a typical week involved patients with chronic pain complaints. They attributed problems with pain care and opioid prescribing more often to patient-related factors such as lack of self-management, and potential for abuse of medication than to provider or practice system factors. Nevertheless, respondents reported inadequate training for, and low satisfaction with, delivering chronic pain treatment. CONCLUSIONS: A substantial proportion of adult primary care appointments involve patients with chronic pain complains. Dissatisfaction with training and substantial concerns about patient self-management and about opioid prescribing suggest areas for improving medical education and postgraduate training. Emphasis on patient-centered approaches to chronic pain management, including skills for assessing risk of opioid abuse and addiction, is required.

Implementing a computer-assisted telephone interview (CATI) system to increase colorectal cancer screening: a process evaluation.

OBJECTIVE: Computer-assisted telephone interviewing (CATI) systems used by telephone counselors (TCs) may be efficient mechanisms to counsel patients on cancer and recommended preventive screening tests in order to extend a primary care provider's reach to his/her patients. The implementation process of such a system for promoting colorectal (CRC) cancer screening using a computer-assisted telephone interview (CATI) system is reported in this paper. METHODS: The process evaluation assessed three components of the intervention: message production, program implementation and audience reception. RESULTS: Of 1181 potentially eligible patients, 1025 (87%) patients were reached by the TCs and 725 of those patients (71%) were eligible to receive counseling. Five hundred eighty-two (80%) patients agreed to counseling. CONCLUSIONS: It is feasible to design and use CATI systems for prevention counseling of patients in primary care practices. PRACTICE IMPLICATIONS: CATI systems have the potential of being used as a referral service by primary care providers and health care organizations for patient education.

Identifying strategies to improve access to credible and relevant information for public health professionals: a qualitative study.

BACKGROUND: Movement towards evidence-based practices in many fields suggests that public health (PH) challenges may be better addressed if credible information about health risks and effective PH practices is readily available. However, research has shown that many PH information needs are unmet. In addition to reviewing relevant literature, this study performed a comprehensive review of existing information resources and collected data from two representative PH groups, focusing on identifying current practices, expressed information needs, and ideal systems for information access. METHODS: Nineteen individual interviews were conducted among employees of two domains in a state health department--communicable disease control and community health promotion. Subsequent focus groups gathered additional data on preferences for methods of information access and delivery as well as information format and content. Qualitative methods were used to identify themes in the interview and focus group transcripts. RESULTS: Informants expressed similar needs for improved information access including single portal access with a good search engine; automatic notification regarding newly available information; access to best practice information in many areas of interest that extend beyond biomedical subject matter; improved access to grey literature as well as to more systematic reviews, summaries, and full-text articles; better methods for indexing, filtering, and searching for information; and effective ways to archive information accessed. Informants expressed a preference for improving systems with which they were already familiar such as PubMed and listservs rather than introducing new systems of information organization and delivery. A hypothetical ideal model for information organization and delivery was developed based on informants' stated information needs and preferred means of delivery. Features of the model were endorsed by the subjects who reviewed it. CONCLUSION: Many critical information needs of PH practitioners are not being met efficiently or at all. We propose a dual strategy of: 1) promoting incremental improvements in existing information delivery systems based on the expressed preferences of the PH users of the systems and 2) the concurrent development and rigorous evaluation of new models of information organization and delivery that draw on successful resources already operating to deliver information to clinical medical practitioners.

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.

Healthcare system factors and colorectal cancer screening.

BACKGROUND: Developing effective programs to promote colorectal cancer (CRC) screening requires understanding of the effect of healthcare system factors on access to screening and adherence to guidelines. METHODS: This study assessed the role of insurance status, type of plan, the frequency of preventive health visits, and provider recommendation on utilization of CRC screening tests using a cross-sectional, random-digit-dial survey of 1002 Massachusetts residents aged > or =50. RESULTS: A broad definition of CRC screening status included colonoscopy or barium enema (screening or diagnostic) within 10 years, flexible sigmoidoscopy (FSIG) within 5 years, and fecal occult blood testing (FOBT) in the past year as options; 51.7% of subjects aged 50 to 64 and 61.5% of older subjects were current. The uninsured had the lowest current testing rate. Among insured participants, type of insurance had little impact on CRC testing; older subjects enrolled in HMOs had marginally higher rates, although not statistically significant. Increased frequency of preventive health visits and ever receiving a physician's recommendation for FSIG or ever receiving FOBT cards were associated with higher rates of CRC screening among both age groups. CONCLUSIONS: Even when broad criteria are used to define current CRC screening status, a substantial proportion of the age-eligible population remains underscreened. Obtaining regular preventive care and receiving a physician's recommendation for screening appear to be potent facilitators of screening that should be considered in designing promotional efforts.