Low Literacy Can Impede Colorectal Ca Screening : Provider education and feedback boosted screening rates in a randomized study.


WASHINGTON – Physician-directed interventions can increase rates of colorectal cancer screening in patients with low literacy skills, Dr. Charles Bennett reported at a conference on health literacy sponsored by the American College of Physicians Foundation.

Patients with limited literacy “may not be able to understand basic cancer screening information and educational materials, many of which are written at a literacy level above that of a significant portion of the American population,” noted Dr. Bennett, a hematologist/oncologist who is an associate director for the Veterans Administration Midwest Center for Health Services and Policy Research.

In a randomized, controlled trial among veterans age 50 years and older seen in two general primary care clinics, the use of provider-directed interventions led to a 26% increase in screening completion among patients with low literacy skills, he said.

No prior study has evaluated the cost effectiveness of health-promotion efforts for colorectal cancer (CRC), but successful interventions have been shown to improve breast and cervical cancer screening rates, he said.

CRC is the third most common cancer in the United States, with the third highest mortality. The American Cancer Society predicts that more than 145,000 adults will be diagnosed with colorectal cancer in 2005 and that 56,000 will die from the disease.

Screening can reduce CRC-related mortality by detecting early-stage CRC. Screening strategies available include the fecal occult blood test (FOBT), flexible sigmoidoscopy, colonoscopy, and double contrast barium enema.

The U.S. Preventive Services Task Force recommends CRC screening for average-risk individuals age 50 years and older, yet less than 53% of the eligible U.S. population has been screened for CRC. “Physician recommendation is the largest predictor of CRC screening guidance,” Dr. Bennett said.

The VA health care system measures screening rates at monthly intervals as part of its quality-enhancement research initiative. Of the 17 measures evaluated in this program, CRC screening has the lowest performance rates, he said. VA studies have not shown racial or ethnic differences in CRC survival rates, but African Americans insured by Medicare or private health insurance have lower 5-year survival rates than whites with the same insurance, Dr. Bennett said.

Veterans who use the VA health care services have especially low levels of health literacy. At the Jesse Brown VA Medical Center in Lakeside, Ill., only 42% of hospitalized VA patients have health literacy skills above the ninth-grade level, he said.

The trial to test health care provider-directed interventions took place at two primary care clinics at the Jesse Brown center from May 2001 to June 2003. One clinic served as the control site and the other was the intervention clinic. Each had three attending physicians and a staff of nurse practitioners and medical residents. Patients had to be at least age 50 years and be scheduled to be seen in one of the two outpatient clinics. Individuals were excluded if they had a personal or family history of polyps, CRC, or inflammatory bowel disease; had completed a FOBT in the preceding year; or had a flexible sigmoidoscopy or colonoscopy in the preceding 5 years.

In the intervention clinic, providers attended quarterly feedback sessions, focusing on individual and group feedback on CRC screening recommendation rates and patient adherence to recommended tests. The physicians and staff also received an overview of CRC screening guidelines as well as practical strategies to communicate with patients who have limited literacy skills. The “continuous quality improvement” (CQI) process–which applies scientific methods to the practice of medicine to help ease a physician's workload, increase patient satisfaction, and reduce malpractice exposure–was introduced to the participants.

Screening recommendation and completion were assessed by a review of electronic health records by research assistants.

Overall, the health care provider-directed intervention resulted in a 7% absolute increase in the rates of CRC screening recommendations, and a 9% absolute increase in the rates of CRC screening completion, Dr. Bennett reported.

Providers who attended at least one feedback session were more likely than those who attended no sessions to make a CRC screening recommendation. In addition, patients of providers who attended at least one feedback session were more likely than those who attended no sessions to adhere to CRC screening recommendations.

Respondents with limited literacy skills were more likely than others to be unfamiliar with CRC and other screening tests for CRC. They also appeared to be more skeptical about the screening process, complaining that an FOBT was inconvenient and messy, and stating they would not use an FOBT even if recommended by their physician. But they were more likely to believe that they were at average to high risk of developing CRC than higher literacy patients, Dr. Bennett said.


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