January/February 2009 Annals of Family Medicine tip sheet

Four articles and an editorial in the January/February issue of Annals look at the issue of colorectal cancer screening and the role of primary care in early detection. Colorectal cancer is the second leading cause of cancer death in the United States, in part because only slightly more than one-half of eligible adults aged 50 years and older report being up-to-date with screening.

In a meta-analysis of 12 studies on the outcomes of screening colonoscopies performed by primary care physicians, Wilkins and colleagues find that colonoscopies performed by primary care physicians appear to be safe and effective, with quality, safety and efficacy indicators comparable to those recommended by specialty societies. Analyzing quality measures from colonoscopies performed on 18,292 patients by primary care physicians, the researchers find that several standard measures of proficiency are similar to those reported for colonoscopies by gastroenterologist specialists. Given the growing demand for screening colonoscopy and the current shortage of endoscopists, they conclude that primary care physicians could play a fundamental role in expanding access.

Using nationally representative data on 120,221 patients, Cardarelli and Thomas show that having a personal health care provider is associated with a three times higher likelihood of colorectal cancer screening. They also find that patients who are older, female, non-Hispanic and white, and have a higher level of education, income and health insurance are more likely to be up-to-date for colorectal cancer testing. Although these covariates are significant predictors, having a personal health care provider has the highest odds of predicting up-to-date screening. They conclude that policy-driven initiatives to ensure all people have access to a primary care clinician may be a strategic method to improving colorectal cancer screening rates and other health outcomes.

Potter and colleagues find that offering home fecal occult blood tests (FOBT) to eligible patients at a primary care-based annual flu shot clinic dramatically increased colorectal cancer screening rates among those in attendance. Specifically, in the study of 514 patients attending an annual flu shot clinic at the San Francisco General Hospital, screening rates increased by 29.8 percentage points among those offered an FOBT (from 54.5 percent to 84.3 percent). This is compared to an insignificant increase of 4.4 percentage points in screening among those who weren't offered test. Researchers conclude that pairing home FOBT kits with annual flu shots may be a useful strategy for increasing colorectal cancer screening rates in primary care or other public health settings.

Jimbo and colleagues examine reasons that positive fecal occult blood tests were not followed up with a complete diagnostic evaluation using colonoscopy or double-contrast barium enema and sigmoidoscopy, finding that in nearly one-half of the cases such decisions were at variance from established guidelines or could not be determined. Analyzing data for 661 patients with positive FOBT results who did not undergo subsequent diagnostic evaluation, researchers found that nonperformance was due to physician decision for 217 (33 percent) of patients. In 94 (14 percent) of those patients, the physicians' reasons for nonperformance were not compatible with established guidelines. For 232 (35 percent) of those patients, there was not a clearly documented reason for nonperformance. The authors conclude that because decision making by primary care physicians appears to have a major effect on nonperformance of a complete diagnostic evaluation after a positive FOBT result, colorectal screening programs should include guidance for physicians about when a complete evaluation should and should not be performed.

An accompanying editorial by the former chair of the US Preventive Services Task Force argues that the findings of the aforementioned studies on colorectal cancer screening have much larger implications for policymakers. He asserts the evidence supports the importance of having 1) a personal health care provider, 2) systems to ensure adherence to proven clinical protocols, 3) systems to deliver indicated services regardless of the reason for visit, and 4) solutions to irrational limitations on clinicians who could otherwise competently provide services. He renews the call for system-wide reform to ensure more effective implementation of preventive screening recommendations.

Screening Colonoscopies by Primary Care Physicians: A Meta-Analysis
By Thad Wilkins, M.D., et al
Medical College of Georgia, Augusta

Having a Personal Health Care Provider and Receipt of Colorectal Cancer Testing
By Roberto Cardarelli, D.O., M.P.H., and Jennifer E. Thomas, B.S.
University of North Texas Health Science Center at Fort Worth, Primary Care Research Institute

Offering Annual Fecal Occult Blood Tests at Annual Flu Shot Clinics Increases Colorectal Cancer Screening Rates
By Michael B. Potter, M.D., et al
University of California, San Francisco

Reasons Patients With a Positive Fecal Occult Blood Test Result Do Not Undergo Complete Diagnostic Evaluation
By Masahito Jimbo, M.D., M.P.H., et al
University of Michigan, Ann Arbor

The Aftermath of Efficacy
By Alfred O. Berg, M.D., M.P.H.
University of Washington, Seattle

The phenomenon of patient medication requests appears to be declining, according to the findings of a study of 1,647 patient encounters at a network of Colorado primary care practices. Researchers found that patient requests for specific new prescriptions were reported in only 3.5 percent of patient visits – about half the rate previously reported in a study published five years ago where researchers found that patients requested at least one prescription medicine in 15.8 percent of encounters. The authors suggest that recent regulations and scrutiny of the direct-to-consumer pharmaceutical advertising environment may explain the decline. Notably, the researchers also found that in those instances when a patient requested a specific medication, it was often not the physicians' first choice for treatment (62 percent), yet the medication was nonetheless prescribed 53 percent of the time. Despite this finding, clinicians reported a negative impact from these requests in only 10 percent of visits.

Lack of Impact of Direct-to-Consumer Advertising on the Physician-Patient Encounter in Primary Care: A SNOCAP Report
By Bennett Parnes, M.D., et al
University of Colorado School of Medicine, Aurora

With as many as 65 percent of heart attack patients reporting symptoms of depression, a systematic review by the American Academy of Family Physicians Commission on Science finds strong evidence for screening patients for depression after heart attack using a standardized symptom checklist. They also find moderate to strong evidence for treatment to improve depression symptoms using selective serotonin reuptake inhibitors (SSRIs) and psychotherapy.

Detection and Management of Postmyocardial Infarction Depression Guideline
Post–Myocardial Infarction Depression Clinical Practice Guideline Panel
Lee A. Green, M.D., M.P.H., et al
University of Michigan, Ann Arbor

With postpartum depression affecting up to 22 percent of women who have recently given birth, Gjerdingen and colleagues identify a feasible strategy for screening in primary care setting. Analyzing survey results from 506 women, researchers conclude the optimal strategy for identifying women with postpartum depression may be a 2-stage screening procedure that involves a 2-item initial screen, followed by a 9-item confirmatory instrument for those whose screening test was positive. They found the 2-item screen to be highly sensitive for identifying those with postpartum depression (100 percent), meaning that it did not miss any cases. In contrast, they found the PHQ-9 tool to be highly specific (92-94 percent) for identifying postpartum depression, indicating a low false-positive rate. They assert this two-stage approach could be easily administered in primary care.

Postpartum Depression Screening at Well-Child Visits: Validity of a 2-Question Screen and the PHQ-9
By Dwenda Gjerdingen, M.D., M.S., et al
University of Minnesota, Minneapolis

Screening for intimate partner violence among 1,026 men seen in an urban emergency department, researchers find the highest rate of mental health symptoms (depression, post-traumatic stress disorder, suicidal ideation, substance abuse) occur among men who disclose both victimization and perpetration. Surveys indicated 37 percent experienced intimate partner violence in their relationships – 20 percent disclosed victimization, 6 percent disclosed perpetration and 11 percent disclosed both. Those who disclosed both victimization and perpetration had the highest frequencies and levels of adverse mental symptoms. Additionally, rates of smoking, alcohol abuse and drug use were higher in those who reported intimate partner violence in their relationships. The authors conclude that screening for intimate partner violence as part of a health risk assessment provides opportunities for new, targeted interventions outside the criminal justice setting. They advise that such interventions must be guided by an understanding of the heterogeneity of male partner violence and co-occurring behavioral and mental health issues.

Intimate Partner Violence and Comorbid Mental Health Conditions Among Urban Male Patients
By Karin V. Rhodes, M.D., M.S., et al
University of Pennsylvania, Philadelphia

A population-based study of 46,371 Dutch children with asthma finds greater prescribing variability in younger children (aged six years and younger) compared with older children. The authors assert this is likely a direct result of the lack of diagnostic tools for young children with asthmatic symptoms. Investigating what other patient, family and physician characteristics influence whether children are given a prescription for asthma medication, researchers find that health-seeking behavior, parental asthma and the attitude and experience of the physician are associated with prescribing asthma medication. Several respiratory diagnoses other than asthma, including bronchitis and cough are also strongly associated with prescribing asthma medication. The authors conclude that diagnostic limitations may result in more physician- and family-driven prescribing, which isn't always in the best interest of the child.

What Drives Prescribing of Asthma Medication to Children? A Multilevel Population-Based Study
By Mira G. P. Zuidgeest, Pharm.D., Ph.D., et al
Utrecht University, The Netherlands

Researchers identify five screening questions and demographics that independently predict whether a patient has limited health literacy: 1) self-rated reading ability, 2) the result of the Single-Item Literacy Screener, a one-question test, 3) highest education level attained, 4) sex, and 5) race. They suggest that clinicians be aware of these associations and ask questions to identify patients who may need assistance with navigating the health care system or understanding health-related materials.

Screening Questions to Predict Limited Health Literacy: A Cross-Sectional Study of Patients With Diabetes Mellitus
By Kelly Marvin Jeppesen, M.P.H., et al
The Ohio Sate University College of Medicine, Columbus

An essay by Buetow uses the art concept of "negative space" to help physicians see patients and situations (and sometimes themselves) in relief, separated from preconception and focused on the moment. He notes how clinicians can easily miss the importance of what is not present – the physical space that separates clinicians and patients during face-to-face encounters, the information not exchanged during the patient visit, and what the patient and clinician do not say to each other between visits. He asserts that by being more aware of and attending to these negative spaces, primary care clinicians can improve the delivery of care.

Something in Nothing: Negative Space in the Clinician-Patient Relationship
By Stephen A. Buetow, Ph.D.
University of Auckland, New Zealand

Annals of Family Medicine is a peer-reviewed, indexed research journal that provides a cross-disciplinary forum for new, evidence-based information affecting the primary care disciplines. Launched in May 2003, Annals is sponsored by seven family medical organizations, including the American Academy of Family Physicians, the American Board of Family Medicine, the Society of Teachers of Family Medicine, the Association of Departments of Family Medicine, the Association of Family Medicine Residency Directors, the North American Primary Care Research Group, and the College of Family Physicians of Canada. Annals is published six times each year and contains original research from the clinical, biomedical, social and health services areas, as well as contributions on methodology and theory, selected reviews, essays and editorials. Complete editorial content and interactive discussion groups for each published article can be accessed free of charge on the journal's Web site, www.annfammed.org.