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Am J Manag Care. Author manuscript; available in PMC 2015 March 13. Published in final edited form as: Am J Manag Care. 2014 July ; 20(7): 555–561.
Patients’ modality preferences, physician recommendations and use of colon cancer screening in primary care Sarah T. Hawley, PhD, MPH1,2, Sarah E. Lillie, MPH3, Greg Cooper, MD4, and Jennifer Elston Lafata, PhD5
Author Manuscript
1
Division of General Medicine, University of Michigan Health System
2
Ann Arbor VA Medical Center
3
Department of Health Behavior and Health Education, University of Michigan School of Public Health
4Case
Western Reserve University Comprehensive Cancer Center
5Department
of Social and Behavioral Health, Virginia Commonwealth University School of
Medicine
Abstract Purpose—To evaluate associations between patients’ CRC test preferences, physician CRC screening recommendations during periodic health exams and subsequent utilization of screening 12 months later.
Author Manuscript
Methods—Audio-recordings of 415 periodic health exams (PHEs) were joined with electronic medical record data and pre-visit patient surveys. Patient ratings of test attributes were used to create an algorithm reflecting CRC test preference at baseline. Physician CRC test recommendations were obtained from audio-recordings. Baseline test preferences and physician recommendations were compared with CRC test use using chi-square tests. Associations between physician recommendation and baseline test preferences were assessed using logistic regression.
Author Manuscript
Results—Few patients had a strong preference for any test; most had a weak preference for colonoscopy (COL) (41%), an unclear preference (22.4%), or a weak preference for FOBT (18.6%). About half (56%) of patients were screened at 12-months and there was no statistical association between baseline preference and type of test received. COL was recommended in 99% of visits, and was recommended in conjunction with FOBT in 29% of visits. Patients were significantly more likely to receive a joint recommendation for COL and FOBT when they had a baseline preference for FOBT (OR: 2.17; 95% CI 1.26-3.71; p$80,000 or more). Analysis
Author Manuscript
Baseline CRC Test Preferences—First, we generated a description of the sample according to the patient demographic factors. To assess the importance of each attribute, we calculated the proportion of patients who ranked each attribute first, second and third. We then applied our algorithm to categorize baseline CRC test preferences into the 5 categories as described above. Next, we evaluated associations between baseline preferences and patient demographic factors using chi square tests. We then conducted multinomial logistic regression (MNL) to further evaluate associations between baseline preferences and patient demographic characteristics using our 3-level preferences variable, with COL as the referent category.
Author Manuscript
Physician CRC Screening Recommendations—We conducted a logistic regression of our 2-level recommendation variable (COL only vs. COL + FOBT) using COL + FOBT as the referent category. We conducted this regression in a stepwise manner, with Model 1 including only patient demographics as independent variables, and Model 2 including both patient demographics and baseline test preferences. Associations with CRC Test Utilization—We compared both baseline test preferences and physician recommendations with CRC screening test utilization 12 months following the PHE using chi-square tests.
Am J Manag Care. Author manuscript; available in PMC 2015 March 13.
Hawley et al.
Page 5
Author Manuscript
Results Participant Characteristics
Author Manuscript
Physician and patient participants/non-participants are described in detail elsewhere (6, 23). Briefly, 47% of physicians and 50% of patients agreed to participate. Among the 500 consenting patient participants, there were 485 audible office visit recordings. Excluded from consideration in the current analyses are visits for which the audio-recording indicated the patient was not due for CRC screening (n=12), the patient had screening scheduled at the time of the visit (n=25), or was in the midst of a related diagnostic workup (n=1). Also excluded are patients for which the pre-visit survey was not available (n=3). The resultant sample consists of 444 unique patient visits. Of these, 93.5% discussed CRC screening with their physician during the periodic health examination (N=415) which is the number used in this analysis. Patients were on average 59 years old (SD=7.9), and typically white (65.5%) and female (64.1%). Patients were highly educated (72.5% attended at least some college) and just over one-third had a household income of over $80,000 (35.9%) (Table 1). Baseline CRC Test Preferences Using our 5-level categorization, we found general few patients strongly preferred COL (7%) or strongly preferred FOBT (11.1%). Most patients had a weak preference for COL (41%), followed by an unclear preference (22.4%), and a weak preference for FOBT (18.6%). We did not find statistically significant differences in baseline CRC test preferences by patient race, gender, education or income. The results of the MNL model with our 3-level categorization of baseline preferences were consistent with those of the bivariate analysis (data not shown).
Author Manuscript
Accuracy of the screening test was most often listed as the most important attribute; it was chosen as such almost half (47.0%) of the time. Following test accuracy, risk of complications was most often chosen as the most important attribute (16.2%). Test preparation or the need to collect a stool sample at home was rarely chosen as the most important attribute (3.7% and 1.7%, respectively). Physician CRC Screening Recommendations
Author Manuscript
Among PHEs with a physician recommendation for CRC screening, COL was mentioned and recommended for CRC screening in almost all PHEs (N= 412; 99.0%), with or without mentioning other tests. In 29.1% of all visits (N=120), the physician recommended both COL and FOBT. Other CRC screening tests (barium enema and sigmoidoscopy) were recommended in a minority of PHEs, and always in conjunction with COL (2 visits each, 0.98% in total). In Model 1, men were significantly less likely than women to receive a a COL + FOBT recommendation than a COL only (OR: 0.52; 95% CI 0.27-0.97, p
Am J Manag Care. Author manuscript; available in PMC 2015 March 13. Published in final edited form as: Am J Manag Care. 2014 July ; 20(7): 555–561.
Patients’ modality preferences, physician recommendations and use of colon cancer screening in primary care Sarah T. Hawley, PhD, MPH1,2, Sarah E. Lillie, MPH3, Greg Cooper, MD4, and Jennifer Elston Lafata, PhD5
Author Manuscript
1
Division of General Medicine, University of Michigan Health System
2
Ann Arbor VA Medical Center
3
Department of Health Behavior and Health Education, University of Michigan School of Public Health
4Case
Western Reserve University Comprehensive Cancer Center
5Department
of Social and Behavioral Health, Virginia Commonwealth University School of
Medicine
Abstract Purpose—To evaluate associations between patients’ CRC test preferences, physician CRC screening recommendations during periodic health exams and subsequent utilization of screening 12 months later.
Author Manuscript
Methods—Audio-recordings of 415 periodic health exams (PHEs) were joined with electronic medical record data and pre-visit patient surveys. Patient ratings of test attributes were used to create an algorithm reflecting CRC test preference at baseline. Physician CRC test recommendations were obtained from audio-recordings. Baseline test preferences and physician recommendations were compared with CRC test use using chi-square tests. Associations between physician recommendation and baseline test preferences were assessed using logistic regression.
Author Manuscript
Results—Few patients had a strong preference for any test; most had a weak preference for colonoscopy (COL) (41%), an unclear preference (22.4%), or a weak preference for FOBT (18.6%). About half (56%) of patients were screened at 12-months and there was no statistical association between baseline preference and type of test received. COL was recommended in 99% of visits, and was recommended in conjunction with FOBT in 29% of visits. Patients were significantly more likely to receive a joint recommendation for COL and FOBT when they had a baseline preference for FOBT (OR: 2.17; 95% CI 1.26-3.71; p$80,000 or more). Analysis
Author Manuscript
Baseline CRC Test Preferences—First, we generated a description of the sample according to the patient demographic factors. To assess the importance of each attribute, we calculated the proportion of patients who ranked each attribute first, second and third. We then applied our algorithm to categorize baseline CRC test preferences into the 5 categories as described above. Next, we evaluated associations between baseline preferences and patient demographic factors using chi square tests. We then conducted multinomial logistic regression (MNL) to further evaluate associations between baseline preferences and patient demographic characteristics using our 3-level preferences variable, with COL as the referent category.
Author Manuscript
Physician CRC Screening Recommendations—We conducted a logistic regression of our 2-level recommendation variable (COL only vs. COL + FOBT) using COL + FOBT as the referent category. We conducted this regression in a stepwise manner, with Model 1 including only patient demographics as independent variables, and Model 2 including both patient demographics and baseline test preferences. Associations with CRC Test Utilization—We compared both baseline test preferences and physician recommendations with CRC screening test utilization 12 months following the PHE using chi-square tests.
Am J Manag Care. Author manuscript; available in PMC 2015 March 13.
Hawley et al.
Page 5
Author Manuscript
Results Participant Characteristics
Author Manuscript
Physician and patient participants/non-participants are described in detail elsewhere (6, 23). Briefly, 47% of physicians and 50% of patients agreed to participate. Among the 500 consenting patient participants, there were 485 audible office visit recordings. Excluded from consideration in the current analyses are visits for which the audio-recording indicated the patient was not due for CRC screening (n=12), the patient had screening scheduled at the time of the visit (n=25), or was in the midst of a related diagnostic workup (n=1). Also excluded are patients for which the pre-visit survey was not available (n=3). The resultant sample consists of 444 unique patient visits. Of these, 93.5% discussed CRC screening with their physician during the periodic health examination (N=415) which is the number used in this analysis. Patients were on average 59 years old (SD=7.9), and typically white (65.5%) and female (64.1%). Patients were highly educated (72.5% attended at least some college) and just over one-third had a household income of over $80,000 (35.9%) (Table 1). Baseline CRC Test Preferences Using our 5-level categorization, we found general few patients strongly preferred COL (7%) or strongly preferred FOBT (11.1%). Most patients had a weak preference for COL (41%), followed by an unclear preference (22.4%), and a weak preference for FOBT (18.6%). We did not find statistically significant differences in baseline CRC test preferences by patient race, gender, education or income. The results of the MNL model with our 3-level categorization of baseline preferences were consistent with those of the bivariate analysis (data not shown).
Author Manuscript
Accuracy of the screening test was most often listed as the most important attribute; it was chosen as such almost half (47.0%) of the time. Following test accuracy, risk of complications was most often chosen as the most important attribute (16.2%). Test preparation or the need to collect a stool sample at home was rarely chosen as the most important attribute (3.7% and 1.7%, respectively). Physician CRC Screening Recommendations
Author Manuscript
Among PHEs with a physician recommendation for CRC screening, COL was mentioned and recommended for CRC screening in almost all PHEs (N= 412; 99.0%), with or without mentioning other tests. In 29.1% of all visits (N=120), the physician recommended both COL and FOBT. Other CRC screening tests (barium enema and sigmoidoscopy) were recommended in a minority of PHEs, and always in conjunction with COL (2 visits each, 0.98% in total). In Model 1, men were significantly less likely than women to receive a a COL + FOBT recommendation than a COL only (OR: 0.52; 95% CI 0.27-0.97, p
