Risk assessment and clinical decision making for colorectal cancer screening.

BACKGROUND: Shared decision making (SDM) related to test preference has been advocated as a potentially effective strategy for increasing adherence to colorectal cancer (CRC) screening, yet primary care providers (PCPs) are often reluctant to comply with patient preferences if they differ from their own. Risk stratification advanced colorectal neoplasia (ACN) provides a rational strategy for reconciling these differences. OBJECTIVE: To assess the importance of risk stratification in PCP decision making related to test preference for average-risk patients and receptivity to use of an electronic risk assessment tool for ACN to facilitate SDM. DESIGN: Mixed methods, including qualitative key informant interviews and a cross-sectional survey. PARTICIPANTS: PCPs at an urban, academic safety-net institution. MAIN MEASURES: Screening preferences, factors influencing patient recommendations and receptivity to use of a risk stratification tool. KEY RESULTS: Nine PCPs participated in interviews and 57 completed the survey. Despite an overwhelming preference for colonoscopy by 95% of respondents, patient risk (67%) and patient preferences (63%) were more influential in their decision making than patient comorbidities (31%; P < 0.001). Age was the single most influential risk factor (excluding family history), with <20% of respondents choosing factors other than age. Most respondents reported that they would be likely to use a risk stratification tool in their practice either 'often' (43%) or sometimes (53%). CONCLUSIONS: Risk stratification was perceived to be important in clinical decision making, yet few providers considered risk factors other than age for average-risk patients. Providers were receptive to the use of a risk assessment tool for ACN when recommending an appropriate screening test for select patients.

Patient navigation to increase mammography screening among inner city women.

BACKGROUND: Lower mammography screening rates among minority and low income women contribute to increased morbidity and mortality from breast cancer. OBJECTIVE: To evaluate the effect of a patient navigation intervention on adherence rates to biennial screening mammography among women engaged in primary care at an inner-city academic medical center. DESIGN: Quality improvement intervention with a concurrent control group, conducted from February to November of 2008. STUDY SUBJECTS: All women in a hospital-based primary care practice aged 51-70 years. Subjects were randomized at the level of their primary care provider, such that half of the patients in the practice received the intervention, while the other half received usual care. INTERVENTIONS: Intervention subjects whose last mammogram was >18 months prior received a combination of telephone calls and reminder letters from patient navigators trained to identify barriers to care. Navigators were integrated into primary care teams and interacted directly with patients, providers, and radiology to coordinate care. Navigators utilized an electronic report to track subjects. Adherence rates to biennial mammography were assessed in intervention and control groups at baseline and post-intervention. KEY RESULTS: A total of 3,895 women were randomized to intervention (n = 1,817) and control (n = 2,078) groups. Mean age was 60, 71% were racial/ethnic minorities, 23% were non-English speaking, and 63% had public or no health insurance. At baseline, there was no difference in mammography adherence between the control and intervention groups (78%, respectively, p = 0.55). After the 9-month intervention, mammogram adherence was higher in the intervention group compared with the control group (87% vs. 76%, respectively, p < 0.001). Except among Hispanic women who demonstrated high rates in both the intervention and control groups (85% and 83%, respectively), all racial/ethnic and insurance groups demonstrated higher adherence in the intervention group. CONCLUSIONS: Patient navigation improves biennial mammography rates for inner city, low income, minority populations.

Feasibility of patient navigation in resident primary care practice: a screening mammography quality improvement initiative.

Patient navigation (PN) has been used to improve breast cancer outcomes but has not been evaluated in resident practices. The objective of this study was to evaluate the feasibility of PN in resident clinics to improve biennial screening mammography. All participants whose last screening mammogram was at 18 months or after received PN. Feasibility outcomes included practicality (ability to carry out intervention), effectiveness (ability of intervention to increase biennial screening mammography rates), and acceptability (resident satisfaction with PN). Despite difficulty contacting patients, we found PN improved screening mammography adherence in resident practices serving vulnerable populations. Adherence rates increased significantly postintervention. Residents reported interest in using PN in practice.

We can do better than last place: improving the health of us women.

Life expectancy for US women lags behind that for women in other countries. Factors contributing to inequitable health for women are complex and include policy, community, healthcare access, and the interaction between the patient and her healthcare provider working within the healthcare system. We propose a societal pyramid of health accounting for the effects of these different factors and their impact on prevention, screening, diagnosis, and management of disease using the examples of smoking and obesity, two of the most important yet modifiable risk factors for chronic disease and death among US women.

La esperanza de vida de las mujeres de los Estados Unidos va por detrás de la de las mujeres de otros países. Los factores que contribuyen a las desigualdades en la salud de las mujeres son complejos e incluyen la política, la comunidad, el acceso a la atención médica y la interacción entre la paciente y su médico que trabaja dentro del sistema sanitario. Proponemos una pirámide social de la salud que dé cuenta de los efectos de esos distintos factores y de su impacto sobre la prevención, detección, diagnóstico y tratamiento de la enfermedad utilizando los ejemplos del tabaquismo y la obesidad, dos de los factores de riesgo más importantes, aunque modificables, de enfermedad crónica y muerte entre las mujeres estadounidenses.

The effect of a primary care exercise intervention for rural women.

OBJECTIVE: Rural women have limited exercise opportunities and significant barriers to engaging in physical activity. This study assessed the effect of a brief primary care based walking intervention in rural women. METHODS: The participants were recruited in March, 2003 by a primary care nurse at three locations in rural Missouri. The enrolled subjects were given a pedometer, exercise videotape and provided exercise counseling at intake and four time points over 6 months. The week 1 pedometer step counts were compared with step counts at 6-month follow-up. RESULTS: Of the initial 75 participants, 61 completed at least one follow up encounter. The participant's mean age was 42.5 years. At intake, the majority of women (90%) exhibited one or more risk factors for cardiovascular disease; 78% were obese or overweight. Although most (62%) women reported being physically active, the mean pedometer reading was low at 6337 steps per day at week 1. Over the follow-up period, participants increased their step counts by a mean of 2573 steps per day (p<.001). Increases in step counts were seen in normal weight, overweight and obese participants. CONCLUSIONS: A simple walking intervention through a primary care practice was effective in increasing the short term walking rates of rural women.

Strategic memory in adults with anorexia nervosa: are there similarities to obsessive compulsive spectrum disorders?

OBJECTIVE: There is growing interest in the relationship between anorexia nervosa (AN) and obsessive-compulsive (OC) spectrum disorders (e.g., OCD, body dysmorphic disorder [BDD]). Previous neuropsychological investigations of OC spectrum disorders have identified problems with the efficient use of strategy on complex measures of learning and memory. This study evaluated nonverbal strategic memory in AN outpatients using an approach previously applied to OC spectrum disorders. METHOD: Eighteen patients with AN and 19 healthy control participants completed the Rey-Osterrieth Complex Figure Test (RCFT), a widely used measure of nonverbal strategic planning, learning, and memory. RESULTS: Individuals with AN differed significantly from healthy controls in the organizational strategies used to copy the RCFT figure, and they recalled significantly less information on both immediate and delayed testing. Multiple regression analyses indicated that group differences in learning were mediated by copy organizational strategies. CONCLUSION: These results are identical to study findings in OCD and BDD, indicating important shared neuropsychological features among AN and these OC spectrum disorders. As in OCD and BDD, the essential cognitive deficit in AN was impaired use of organizational strategies, which may inform our understanding of the pathophysiology of AN and potentially offer treatment implications.