Current Studies

Multi-level Approaches to Improve Colon Cancer Screening: R-21
Geoffrey Goldsmith, MD, MPH, Principal Investigator
Funded by: National Institutes of Health/National Cancer Institute
1R21CA106936-

Abstract
Colorectal cancer is the second leading cause of cancer deaths in the United States. Screening rates remain disappointingly low despite the disease being as much as 90% preventable through screening and early detection. Low screening rates can be attributed to various patient, physician and practice factors. This study tested the effectiveness of a multimodal intervention designed to address common factors within family medicine settings that create barriers to screening. Primary Care Physicians (PCPs) were recruited from OzarkNet. A total of 18 physicians and one nurse practitioner in 13 different primary care clinics in Arkansas participated. Randomization occurred by site. A six-hour nurse training workshop was held at the University of Arkansas for Medical Sciences for experimental site nurses before the project began. Workshop goals included: educating experimental site nurses on the purpose of the project, identifying key roles and responsibilities of parties involved, preparing nurses for integration of the project into each clinic, and providing skills to complete their role within the project, including motivational interviewing to address patient barriers and prompting physicians to discuss and order CRC screening. Experimental participant recruitment began in November 2005 and ended in June 2006, typically involving 2-3 clinics at a time for periods of up to 16 weeks per clinic. Patients with scheduled appointments with their PCP for any reason were screened for initial inclusion criteria: ages 51 and older, ability to understand English, lack of CRC screening completion consistent with the American Cancer Society (ACS) guidelines, lack of screening orders consistent with ACS guidelines, no current cancer or cancer treatment, and lack of severe mental illnesses that would interfere with the informed consent process. Patients meeting inclusion criteria and who were interested in participating were taken through the informed consent process by the research assistant and shown the patient education video in the exam room on a laptop computer or portable DVD player. After watching the video, the participant completed a questionnaire to evaluate the video, and the nurse entered the room and asked the participant if he or she had any questions about the screening and if they intended to ask their physician to order CRC screening. Patient concerns were addressed using a motivational nurse script in accordance to the patient stage of change. Physician prompts were placed on the outside of the participants chart indicating which screening modality the nurse felt would be most appropriate. The physician conducted the exam in normal fashion and, if appropriate, ordered screening. A two month follow-up phone call was placed to the patient to assess their screening status and assist in screening completion if necessary, and a final 6 month follow-up call was made. Control participants were recruited using retrospective chart reviews for patients seen during the same time period as experimental participants. Participant questionnaires were completed by mail or by phone with research assistants. Focus groups were conducted for experimental site physicians, experimental site nurses, and 16 participants. The physician and nurse focus group analysis is completed. Preliminary analysis of early waves of data suggest an increased screening rate for the intervention group when contrasted with the control group. Final statistical data analysis for screening orders rate and screening compliance rate is underway. Analysis for patient focus groups are being conducted soon and will be completed by June 2007.

Arkansas Colorectal Cancer Demonstration Project
Ronda Henry-Tillman, MD, FACS, Principal Investigator
Geoffrey Goldsmith, MD, MPH, Co-Principal Investigator
Funded by: Arkansas State Legislature
1113005604

Abstract
This study evaluates procedures to promote participation in a pilot public health program designed to provide colorectal screening for low income Arkansans. The study will analyze data collected by the program to document the delivery and impact of public health services. Uninsured and underinsured patients 50 years of age and older with household incomes falling within 200% of the federally defined poverty level are eligible to enroll in the pilot public health program that will be implemented in collaboration with 10 primary care practices. A sample of 1000 patients will be referred for services to screen approximately 400 patients. General Screening Promotion procedures based on professional and patient education strategies will be implemented in all 10 participating practices. In 5 of the 10 practices, general procedures will be augmented with Tailored Screening Promotion procedures based on behavior change principles drawn from Social Cognitive Theory. Procedures implemented in participating clinics include monthly meetings with health care professionals to set screening goals, monitor referral rates, and provide performance based feedback. Procedures implemented with participating patients will include periodic phone calls to identify resources to facilitate adherence to screening recommendations and address barriers that may interfere with scheduled screening appointments. Patients will be contacted 6 months after enrollment to assess self-reported screening uptake and satisfaction with public health services, and to re-assesses cancer-relevant knowledge and attitudes. Screening facilities will be contacted to verify screening results and follow-up recommendations. Data analysis will include descriptive statistics to summarize process and outcome measures as well as analyses examining the association of screening uptake with screening promotion strategies, characteristics of referring primary care practices, and patient characteristics. Pilot data will be used to: estimate baseline screening rates; monitor program implementation and outcomes; develop effect size estimates to be used in the preparation of subsequent research proposals; and to evaluate the relative efficacy of General and Tailored screening promotion strategies for promoting patient adherence to colorectal screening recommendations as measured by FOBT, Flexible sigmoidoscopy and colonoscopy; to identify patient , regional, and clinic/service characteristics associated with patient adherence to screening recommendations.

Pending Studies

Improving Compliance with Colorectal Cancer Screening in Family Medicine Residencies:
Geoffrey Goldsmith, MD, MPH, Principal Investigator

Regrettably, the salutary impact of colorectal cancer (CRC) screening is limited in part by the low rate of enrolling patients in CRC screening in primary care settings. The nation’s CRC screening rate falls far below the American Cancer Society’s goal for 2015 of 75% of the population at risk be screened. Because of this, it has been estimated that 50% of the deaths from CRC could be avoidable, but this reduction can not be achieved unless the population at risk is screened. One way we propose to increase CRC screening is to ensure that primary care practices optimize patient screening among their patients by dissemination of best practices to primary care sites that use Electronic Medical Records (EMR).

We are proposing to use a set of effective and innovative approaches to improve CRC screening. Included in our approach to disseminate best CRC screening practices in the primary care office setting, are four complementary and synergistic approaches. We have found that many sites that have EMRs have not implemented software that maximizes the site’s ability to enhance the delivery of cancer preventive services. The value of this study is that exquisite attention is paid to assembling a set of approaches as part of an acceptable intervention package that can be generalized to primary care practices that use electronic medical records (EMRs). An experienced team of investigators will fastidiously implement of the proposed approach. We will have XX primary care sites in the experimental group and XX primary care sites serve in the control groups. There will be a total of XX primary care providers in each of the study groups.

At the experimental sites, we will focus on assisting the control group clinicians achieve best clinic practices in cancer screening through a combination of on site seminars, enhancements in the EMR, demonstrating how to redesign the clinical practice, and brief behavioral interventions making use of the office nurse. The control sites will receive a CME lecture on CRC screening and cancer patient education information. At the end of the study, we will disseminate the findings of the study through seminars, workshops, and consultation services.

R-01 Video NIH Grant Proposal
Geoffrey Goldsmith, MD, MPH, Principal Investigator
Through previous research within our network we have increased the screening rate for colorectal cancer from a baseline rate of about 20% to as high as 70% in a variety of primary care settings by providing patient education. Development of state of the art patient education tools will likely lead to an even higher rate of compliance for both colon cancer and breast cancer. The goal of this project is to increase the rate of colorectal cancer screening and breast cancer screening through the use of new technology in patient education. We are interested in exploring the effectiveness of an interactive risk based DVD featuring the patient’s personal physician versus the same educational message featuring a professional narrator. In addition we will research whether the interactive aspect of the patient education tool is more effective on screening outcomes than a linear version of the same message. These patient education interventions will occur while the patient is waiting to see the primary care physician during a scheduled prevention visit or an acute visit.

Improving Happiness of Cancer Survivors
Geoffrey Goldsmith, MD, MPH, Principal Investigator
Approximately 50% of long term cancer survivors will experience emotional distress post diagnosis and treatment for their cancer. In this study, we are exploring strategies to improve the mental health of cancer survivors through a team approach that includes primary care clinicians, mental health professionals, and community resources.

Completed Studies

Multi-level Approaches to Improve Colon Cancer Screening: A Pilot Study
Geoffrey Goldsmith, MD, MPH, Principal Investigator
Funded by: UAMS intra-mural grant fund
This project was a developmental and exploratory study designed to investigate the effectiveness of strategies to increase the colorectal cancer (CRC) screening rate in rural family practices. The primary outcomes were the intention to receive CRC screening and the actual rate of adherence with the US Multi-Society Taskforce on Colorectal Cancer screening protocol six months after intervention. This study involved testing the effectiveness of multi-intervention package to increase CRC screening that included use of a video within the office setting, LPN scripted responses to patient resistance to CRC screening and family physician endorsement of screening - all of which took place within the family practice clinic. Three academic based family medicine residency clinics participated in this study which was completed in 2006. The results demonstrated the approach was feasible and dramatically increased the CRC screening rate.

Development and Testing of a Patient Education Videotape on Colorectal Cancer Screening:
Marilyn D. Marshall, MD, Principal Investigator
Geoffrey Goldsmith, MD, MPH, Co-Principal Investigator
Funded by: National Cancer Institute
# U01 CA 096081-05
This study was aimed at improving colorectal cancer screening rates in the African-American population. Drs. Marshall and Goldsmith developed four educational videotapes using input from Pat Vanatta, MSPH, a health educator, Tracy Stecker, PhD, a behavioral psychologist, and focus groups comprising of African-American family medicine patients. A supplementary booklet was also created as a patient education tool. The videos featured the most recent screening recommendations, were adjusted for lower literacy patients, and were tailored to an African-American audience. It was hypothesized that patients were more likely to respond to colorectal cancer screening education if their own physician deliverd the message in the video. The hypothesis was tested in the Betton Clinic in Little Rock and in the AHEC-South Arkansas in El Dorado. Data analysis is underway and study results will be available in 2007.

Improvement in the Outpatient Care of Adult Type II Diabetic Patients Through the Use of Internet Based Strategies and Person to Person Health Educator:
Geoffrey Goldsmith, MD, MPH, Principal Investigator
Funded by: American Academy of Family Physicians Foundation
This study investigated whether use of Internet websites for patient education impacted on the physiological and functional status for the diabetic patient, as well as, sense of patient empowerment. The patient population included adults with Type II Diabetes who already knew how to use the internet. Functional and behavioral status was assessed with the SF-36 and the Zung depression inventory. Experimental patients received a training session on the use of several diabetes specific websites, including a brief overview of how to evaluate the scientific credibility of diabetes websites. These patients also received monthly individualized preventive and surveillance e-mails, based on their individual disease profile, consistent with the ADA guidelines. It was hypothesized that using the Internet for health education would lead to improved physiological and functional status. The results will be available in 2007.