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 ….