armin shahrokni
TRANSCRIPT
Armin Shahrokni
Dr. Hee-Soon Juon
May 2010
Johns Hopkins
Bloomberg School of Public Health
Significance of Topic
Age-Adjusted U.S. Death Rates and TrendsSEER data 1975-2006
Analysis of air contrast barium enema, computed tomographic colonography, and colonoscopy: prospective comparison. Lancet 2005
Five-year Relative Survival Rates Among Patients Diagnosed with CRC by Race and Stage at Diagnosis, United States, 1996-2004.
*Colonoscopy is an effective screening measure *Earlier diagnosis will lead to better survival
Significance of Topic
Significance of the Topic Rate of Adherence: Far from Ideal
MMWR Morb Mortal Wkly Rep. 2008 Mar 14;57(10):253-8
Barriers to Access
Provider Practices, Knowledge, PoliciesPatient
Knowledge & Attitudes
Failure to promote CRC screening/ colonoscopy
Missed Visits Preventive Care
Missed Opportunities
@Sick Visits
@Well Visits
Health Belief Model Framework for CRC Screening Adherence
Trans-Theoretical Framework for CRC Screening Adherence
Life Cycle of Human
Health Promoting Hospitals
Shift in in-patient demographics
Age distribution of admitted patients from 1970 to 2006 Length of Stay in Hospital and Age of patients.
Primary aim: to assess the efficacy of the proposed intervention on patients’ adherence to CRC screening guideline (undergoing colonoscopy)
Null hypothesis: our proposed intervention will not have any impact on adherence rate.
Secondary aims: 1) to assess the change in patients’ perception toward CRC and CRC screening before and after the intervention (HBM). 2) to assess the change in behavioral staging of participants toward CRC screening
Preliminary Information: 352 patients hospitalized in GH above age 50 surveyed. 45% never had colonoscopy. Of these, 70% said they will get colonoscopy if strongly recommended
by physician. Almost 40% prefer to have colonoscopy within 4 weeks of hospital stay. 87% consider themselves as “low risk” for developing CRC. Almost 65% have never looked for information on CRC. 93% said “CRC could be cured if detected early” Almost 70% did not worry about getting CRC.
Study Site:
Randomized Study. 195 patients in intervention group, 195 in control group. Inclusion Criteria:
Age above 50 less than 75.
No prior colonoscopy within the past 10 years.
Exclusion Criteria:
Advanced dementia or cognitive impairment.
History of any Stage IV cancer.
NYHA Class IV heart failure
Patients on hospice care.
patients admitted to ICU on admission or during hospital stay.
Hospitalization due to gastrointestinal symptoms necessitating colonoscopy during hospitalization or as an outpatient.
Study Design
HBM Survey 30-item questionnaire. 4 dimensions: beneficence, barriers, cues to action and self efficacy.
Dimension Maximum score
Minimum score
Beneficence 32 8
Barriers 40 10
Cues to action 16 4
Self efficacy 32 8
Total score 120 30
McQueen A, Tiro JA, Vernon SW. Construct validity and invariance of four factors associated with colorectal cancer screening across gender, race, and prior screening. Cancer Epidemiol Biomarkers Prev. 2008 Sep;17(9):2231-7
TTM survey Which one of these statements applies to you the most? (Only one
statement)I have not heard of colorectal cancer. I have heard of colorectal cancer but have not heard about
colorectal cancer screening. I have heard of colorectal cancer screening but I do not intend
to get one. I have heard of colorectal cancer screening and intend to get
one in near future.
Independent variable: Intervention +/-Dependent variable: getting colonoscopy within 3 months.
/change in HBM survey score and behavioral staging. Intervening Variables: age, education, income, gender,
insurance, number of co-morbidities, BMI, smoking, residency status (home vs. nursing home), marital status, race/ethnicity
Study Design
Patients hospitalized in Griffin Hospital
Research nurse Assess eligibility
Eligible patients Explain study and obtain verbal & written consent
Enrolled patients Randomization allocation software
Control group Intervention group
HBM & TT survey
Educational pamphlets from CDC regarding CRC, its risk and benefits of screening , ways of screening
PROCESS ROAD MAP
CDC SCREEN FOR LIFEEDUCATIONAL PAMPHLETS
CDC SCREEN FOR LIFEEDUCATIONAL PAMPHLETS
Research FlowchartParticipants in intervention group
Research nurse
Griffin GI Department
Try to schedule patients in their first preferred time
Give the written instruction about timing of colonoscopy, preparation for colonoscopy for the day and night before the procedure, Direction to Griffin GI department contact numbers
Obtain 3 time preferences for colonoscopy
PROCESS ROAD MAP
Intervention Group
GI DepartmentOne week after scheduled date
Research Nurse
Colonoscopy performed?
YES
Call participant
HBM survey
END
NOCall participant
HBM surveySpecific reason for declining colonoscopy
Participant wants 2nd appointment? NO
TTM survey
YES
Contact GI department
Schedule patient Repeat steps after scheduling patient
PROCESS ROAD MAP
Control group
Research nurse 3 months post discharge
Phone call
Colonoscopy performed?YES
All patients
Participant answers the phone?NOTry 3 times in 2 weeks
Participant answers the phone?
NO
YES
NO
HBM & TT survey
Obtain contact info of Gastroenterologist who have done the procedure
HBM survey
Contact Gastroenterologist to verify the report
END
PROCESS ROAD MAP
Statistical Analysis Comparison of 2 groups:
- t test for continuous variables
- λ² test for categorical variables
Outcome:
- t test for comparison of different proportions undergoing colonoscopy.
- t test for change in HBM score for pre-post intervention.
- t test for the comparison of HBM score changes in 2 groups.
- λ² for change in TTM staging for pre-post intervention.
- The difference in outcomes will be adjusted based on intervening variables.
Summary Unique study.Looking into the collaboration between ambulatory
settings, hospitals, communities and people for health promotion.
If it shows the positive impact, especially community hospitals may look for other ways of promoting health in in-patient setting.
It boosts the current interventions for community and ambulatory clinics by adding another dimension to interventions.
THANK YOU ….