Promoting CRC Screening in an Urban Minority Population
Condition: Colorectal Cancer
MeSH terms: Colorectal Neoplasms
Study type: Interventional

Summary: 
      The purpose of this study (Healthy Colon Project II) is to evaluate different educational
      approaches for increasing rates of colorectal cancer (CRC) screening in a hard-to-reach urban
      minority population with health insurance.
    

Detailed description: 
      This project is an extension of the investigators' earlier study (Healthy Colon Project I) in
      which the investigators demonstrated that telephone outreach to individuals had a significant
      effect on CRC screening in a hard-to-reach, working class, urban minority population (~27.0%
      screened who received telephone outreach vs. ~6.1% screened who received printed educational
      materials). Additional investigation suggested the possible benefits of intervening with
      primary care physicians (PCPs) regarding their CRC screening referral and follow-up
      practices.

      In the current project, the investigators conducted a 3-group randomized trial. The aims are
      as follows: Aim 1: Evaluate the incremental effect of tailored telephone education (TTE),
      over and above the effect of academic detailing (AD), for increasing rates of CRC screening
      12-months post-randomization; Aim 2: Evaluate the effect of academic detailing alone (AD)
      over minimal intervention (control group), for increasing rates of CRC screening 12-months
      post-randomization; Aim 3: Identify factors that mediate the effectiveness of the
      interventions; and Aim 4: Identify factors that moderate the effectiveness of the
      interventions among subgroups.

      In one group, participants received printed education materials. In a second group,
      participants' PCPs received academic detailing (AD) to improve CRC screening referral and
      follow-up practices. And in a third group, PCPs received AD and participants received
      tailored telephone education (TTE). Participants were members of a union-based,
      self-administered and self-insured benefit fund in the NYC metropolitan area.

      The educational intervention approaches were informed by the investigators' earlier study
      among this population, with the goal of helping participants to make an informed choice about
      screening. The CRC PEM described the importance of early detection and prevention, risk
      factors, and the importance of talking to the subject's doctor about CRC screening. The PEM
      highlighted colonoscopy as being the only test that can identify and prevent CRC and
      described how to prepare for a colonoscopy beginning seven days prior to the test. The PEM
      also described other CRC screening tests, including the FOBT, FIT, sigmoidoscopy, barium
      enema and virtual colonoscopy. Academic detailing (AD) involved an in-person visit from a
      member of the research team who attempted to communicate strategies for improving CRC
      screening uptake in the practice's patient panel. In cases where the PCP was unavailable, an
      office staff member was approached. A brief description of the RCT was followed by a
      semi-structured interview assessing usual practice regarding CRC screening referral and
      follow up. The direction of the discussion was guided by PCP responses. A variety of
      resources were provided: a binder with up-to-date scientific evidence about CRC screening
      recommendations and printed patient education materials, and order forms for refilling
      supplies. Specific directives were following up to make sure patients had made appointments
      with a gastroenterologist and offering 3-day FOBT. The detailer attempted to elicit a verbal
      commitment to do at least one new thing to strengthen the probability that patients would be
      screened. The TTE was based on the investigators' previously tested model and involved a
      semi-structured protocol in which the first goals were to build rapport and assess level of
      knowledge and readiness to be screened. In contrast to the earlier RCT, the current study's
      TTE clearly represented colonoscopy as the screening method of choice, while encouraging
      alternative screening methods as well. This emphasis was consistent with goals of the New
      York City Department of Health and Mental Hygiene and the American Cancer Society at the time
      of the study. Rapport established, the TTE dialogue focused on identifying and addressing
      barriers that might impede receipt of screening. Verbal commitments were elicited: to speak
      with the PCP and make an appointment for a colonoscopy, or request a home stool test, as
      appropriate. Follow up calls assessed progress towards achieving goals.

      Three types of data were collected. Baseline survey data assessed eligibility and measured a
      variety of demographic and other variables. Implementation data monitored the extent to which
      the AD and TTE interventions had been conducted as planned. And outcome data (CRC screening
      one year post-randomization) was based on medical claims data.
    

Intervention name(s): Printed Education Material; Academic Detailing; Academic Detailing+Telephone Education
Intervention type(s): Other; Other; Other
Intervention description(s): The printed education material described the importance of early detection and prevention, risk factors, and the importance of talking to your doctor about CRC screening. The PEM highlighted colonoscopy as being the only test that can identify and prevent CRC and described how to prepare for a colonoscopy beginning seven days prior to the test [18]. The PEM also described other CRC screening tests, including the FOBT, FIT, sigmoidoscopy, barium enema and virtual colonoscopy.; Academic detailing (AD) involved an in-person visit from a member of the research team who attempted to communicate strategies for improving CRC screening uptake in the practice's patient panel. A brief description of the RCT was followed by a semi-structured interview assessing usual practice regarding CRC screening referral and follow up. The direction of the discussion was guided by PCP responses. A variety of resources were provided. Specific directives were following up to make sure patients had made appointments with a gastroenterologist and offering home stool tests. The detailer attempted to elicit a verbal commitment to do at least one new thing to strengthen the probability that patients would be screened.; PCPs received AD as described in the Academic Detailing arm. In addition, participants received tailored telephone education (TTE) which focused on identifying and addressing barriers that might impede screening. Verbal commitments were elicited to speak with their PCP and make an appointment for a colonoscopy, or request a home stool test, as appropriate. Follow-up calls assessed progress towards achieving goals.
Other intervention name(s): Print education; Academic Detailing+Tailored Telephone Education
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Single (Outcomes Assessor)
Primary purpose: Screening
Keywords: colorectal cancer screening