Colorectal Cancer Screening Practices among Texas Nurse Practictioners and Physician Assistants. Authors Laird, Sandra Anne; Raudonis, Barbara M.

Transcription

1 The Henderson Repository is a free resource of the Honor Society of Nursing, Sigma Theta Tau International. It is dedicated to the dissemination of nursing research, researchrelated, and evidence-based nursing materials. Take credit for all your work, not just books and journal articles. To learn more, visit Item type Format Title Presentation Text-based Document Colorectal Cancer Screening Practices among Texas Nurse Practictioners and Physician Assistants Authors Laird, Sandra Anne; Raudonis, Barbara M. Downloaded 17-Jul :26:36 Link to item

2 Colorectal Cancer Screening Practices Among Nurse Practitioners and Physician Assistants in Texas Sandra A. Laird, DNP, RN., ACNP-BC, AOCNP Barbara M. Raudonis, PhD, RN, FNGNA, FPCN

3 Disclosures We have no conflicts to disclose

4 Colorectal Cancer Cancer that begins either in the colon or the rectum Multiple stages Preventable

5 Stages of Colon cancer Prevention 5 year Survival Rates 80%-95% 55%-80% 40% 12% Spruce, L. R., & Sanford, J. T. (2012). An intervention to change the approach to colorectal cancer screening in primary care. Journal of the American Academy of Nurse Practitioners, 24, doi: /j x medicinenet.com/script/main/art.asp?articlekey=18349 Oct 4,2015

6 Health Problem USPSTF recommends colorectal cancer (CRC) screening for adults age ACS (2015) goal 75% of all adults 50 years and older being current on CRC" Nationally, only 59% to 65% of those 50 years and older are current on CRC

7 Colorectal Cancer Screening Algorithm

8 Screening Tests for CRC Screening Test Sensitivity Specificity Cost Interval Follow Up if Positive gfobt Variable Variable Low Annual Colonoscopy ifobt Variable Variable Medium Annual Colonoscopy sdna Variable High High 3 years Colonoscopy DCBE Low Low Low 5 years Colonoscopy Flex Sig Medium Medium High 5 Years Colonoscopy Endoscopic Colonoscopy Computed Tomographic High High High 10 Years* Risk Perforation Bleeding Medium Medium High 5 years Polyps require Colonoscopy

9 Health Problem In 2012, Texas ranked 41st in prevalence of adults aged 50 and older who were current on colorectal (CRC) screening Screening rate for Texas 57% Less than 55% % of Latinos and 56% of African Americans are current on CRC screening Less than 40% of people at lower socioeconomic levels are current with CRC screening (National Cancer Institute, 2014) (Siegel, R. L., Miller, K. D., & Jemal, A., 2015)

10 Significance Colorectal Cancer (CRC) Rivals heart disease as #1 killer in ages Third most common cancer diagnosis in U.S. Second leading cause cancer death in cancers affecting men and women 132,700 new cases CRC 2015 Texas 10,050 50,000 deaths projected in 2015 Texas 3,470 (Siegel, R. L., Miller, K. D., & Jemal, A. 2015)

11 Significance Economic Burden of CRC 2013 direct cost of treating CRC $17 billion 9.8 million work days lost due to hospitalization By 2020 Using a trending model Considering decreasing incidence, improved survival, and increasing costs $5.19 billion, initial care $3.57 billion, continuing care $5.27 billion. Last yr life 53% increase in CRC care costs for people 65years and older under a fixed current incidence model (Yabroff et al. 2008)

12 Review of Literature Inconsistencies in CRC screening guidelines (ACS; USPSTF; AGA; ASCO) - provider confusion and disagreement with screening guidelines (Schwaiger et al. 2013) If a is polyp found on a colonoscopy it is no longer screening (Green & Coronado,2014) Provider recommendation most powerful determinant of patient uptake and adherence (Power, et al.) Lack of documentation of 3 generation family history prevents identification of persons at increased risk for CRC (Kelly,2011)

13 Review of Literature Reasons for Low CRC Screening Rates Lack of time in a busy practice Costs to the patient Lack of adequate reimbursement Lack of a tracking system Lack of administrative support Demand to see increased numbers of patients Patient lack of understanding of the benefits of screening Patient non compliance (Reed, C., & Selleck, C., 1996; Reeve, K., Byrd, T., & Quill, B. E., 2004; Spruce, L. R., & Sanford, J. T., 2012)

14 Review of Literature No previous studies comparing Texas NPs and PAs with regard to CRC screening were found.

15 Purpose Describe the beliefs, attitudes, practices, and knowledge of Texas NPs and PAs with regard to risk stratified colorectal cancer screening in adults.

16 Framework: Theory of Planned Behavior Actual Control Figure 3. Project framework: Adapted from Theory of Planned Behavior. From Ajzen, I. (1991). Organizational Behavior and Human Decision Processes

17 Design Descriptive Correlational Comparative

18 Research Questions 1. What are the beliefs, attitudes, and practices, among NPs and PAs with regard to CRC screening in adults? 2. Is there a relationship between provider demographics and CRC screening? 3. Are there differences between NPs and PAs in knowledge of national screening guidelines for adults at varying risk of CRC and their CRC screening behavior?

19 Data Collection Data were collected with a researcher developed, web-based survey using Qualtrics (Version 12018) Data were collected from July 24,2014 through October 21,2014

20 Results

21 Sample Demographics Characteristics of Sample Gender a Male Female Race /Ethnicity White / Caucasian Black or African American Asian Native American / Alaskan Hispanic Other Average Age Length of time in practice Specialty Family Practice Work Setting Private Physician Practice NP n (%) 17 (10.2) 148 (88.6) 122 (73.1) 9 (5.4) 4 (2.4) 1 (.6) 25 (15) 4(2.4) (SD 10.5) M 10 years 59% 39% PA n (%) 30 (33) 61 (67) 77 (81.9) 7 (7.4) 2 (2.1) 0 8 (8.5) (SD 13.7) M 12 years 55.3% 56.4% Numbers reflect missing data a May represent respondents who gave incomplete responses

22 Provider Specialties Specialty NP n (%) PA n (%) Family Practice 99 (59.3) 52 (55.3) Internal medicine 1 (1.4) 9 (9.6) Geriatrics 8 (4.8) 0 Oncology/Hematology 3 (1.8) 6 (6.4) Women s Health 21 ( (1.1) *Other 17 (10.2) 26 (27.7) Total 167 (100) 94( 100) *gastroenterology, cardiology, surgery, neurosurgery, endocrinology, urgent care, orthopedics, urology, men's health, nephrology, transplant, infectious disease, radiation oncology, and dermatology

23 Screening Practices NP N(%) N(%) PA * N(%) N(%) Order Mammogram Yes No Yes No 148 (88.6) 10 (6) 75 (82.4) 16 (17.6) Order Pap 134 (80.2) 27 (16.2) 52 (57.1) 32 (35) Order FOBT 125 (74.9) 36 (21) 62 (68.1) 29 (31.9) Order Fit 26 (15.6) 135 (80.8) 14 (15.4) 76 (83.5) Order Colonoscopy 142 (85) 19 (11.4) 79 (86.8) 12 (13.2) *Numbers do not equal 100% due to missing and incomplete data

24 Knowledge of CRC Guidelines Knowledge item (correct answer) Correct Answers NP n (%) PA n (%) *Age to begin CRC screening in average risk adult (50) 126 (88.6%) 75 (95.6%) *Evaluation of patient with adenomatous polyp diagnosed >10years ago (colonoscopy) 157(94%) 89 (97.8%) Lifetime risk Lynch Syndrome associated CRC 147 (18.6%) 81 (40.7) Lifetime risk Lynch associated endometrial cancer(ec) 141 (34.1% 81 (28.6) *Screening frequency in a patient with Lynch syndrome (every 1-2 years) *Age to start colonoscopy in a patient with Lynch syndrome (20-25) *Age to begin screening in a patient with two or more first degree relatives of any age or a first degree relative <60 (40) Follow up for positive FOBT or FIT (colonoscopy) 151 (18.6%) 23 (25.3%) 66 (43.7%) 47 (56.6%) 79 (49.7%) 55 (61.8%) 157 (94) 89 (97.8) Items included in composite knowledge score

25 Knowledge of Hereditary Cancer Syndromes Item NP n (%) PA n (%) Obtain a three generation family history of cancer 166 (40.1%) 91 (39.6%) Confidence in knowledge of hereditary cancer syndromes 167 (60.5%) 91 (57.2%) Familiar with Lynch syndrome formerly called HNPCC 166 (43.1%) 91 (65.9%) Lifetime risk Lynch associated CRC (60%-80%) 147 (18.6%) 81 (40.7%) Lifetime risk Lynch associated EC (40%-60%) 141 (34.1%) 78 (52.8%) Positive personal or family history CRC <60 refer to genetic counselling 159 (50.9%) 88 (47.3%) Positive personal or family history EC <60 refer to genetic counselling 160 (37.7%) 88 (39.6%)

26 Results An independent samples t-test was conducted to compare NP and PA knowledge of national CRC screening guidelines

27 NP and PA Knowledge of National Screening Guidelines There was a significant difference in the scores for NPs (M = 3.09, SD =.96) and PAs (M = 3.44, SD =.85) in knowledge of national CRC screening guidelines for adults at varying risk for CRC t 2.8 (222), p <.005

28 NP and PA Knowledge of National Screening Guidelines There was no significant difference between NPs (M = 1.82, SD =.59) and PAs (M = 1.70, SD =.69) in CRC screening behavior t 1.5 (249), p >.05

29 Relationships of Provider Demographics to CRC Screening There was no significant relationship between provider demographics and screening behaviors. There was a moderate positive relationship between percent of patients classified as primary care and CRC screening r = 0.330, n = 251, p = <.01 There was a moderate negative relationship between specialty and CRC screening behavior r = -.410, n = 251, p <.01

30 Relationship between social Norms and Control There was no relationship between perceived social norms or perceived behavioral control and CRC screening There was a very weak negative relationship between actual control and CRC screening r = -.227, p <.01

31 Discussion The findings supported the respondents' knowledge of national screening guidelines for breast, cervical, and colorectal cancer in average risk adults. Knowledge gaps were identified in both groups as evidenced by the responses to the five vignettes that addressed risk stratified screening for CRC and the responses to questions about Lynch associated cancers

32 Discussion Only 39.6% of the PAs and 40% of the NPs reported performing a three generation family history The responses revealed a lack of knowledge of the association of CRC and endometrial cancer (EC) diagnosed before the age of 60 with Lynch syndrome The responses revealed knowledge gaps indications for referral to genetic counseling

33 Implications for the Future Increased Demand for Colorectal Cancer Screening Aging population (ACS, 2014) Doubling of demand for cancer services in next 10 years million Americans may gain access to care through the Affordable Care Act (Eastman, 2014) Decreased Physician Supply (Eastman, 2014) Primary care workforce (Spruce & Sanford, 2012) Oncology workforce (Eastman, 2014)

34 Conclusion NPs and PAs will need to fill the primary care workforce shortage to provide comprehensive cancer screening NPs and PAs outside traditional oncology practices will need to assume more comprehensive cancer screening, co-management, and post treatment surveillance To do this, NP and PA training programs need to find ways to increase cancer prevention and surveillance content in their curricula NPs and PAs could benefit from continuing education in risk stratified CRC screening Reed, C., & Selleck, C. (1996). The role of midlevel providers in cancer screening. Medical Clinics of North America, 80(1),

35 Limitations Convenience sample TNP & TAPA members Small sample size (n = 258) Low response rate (7.3%) Self-report bias Researcher-developed survey Results not generalizable beyond Texas

36 Aknowledgements Project advisor Dr. Barbara Raudonis Clinical advisor Dr. Reni Courtney Statistical Advisors Dr. John Connolly Dr. Daisha Cipher

37 References ACS. (2014). Colorectal cancer facts and figures Retrieved from ACS. (2015). Cancer facts and figures Retrieved from American Nurses Association. (2009). Consensus model for APRN regulation licensure accreditation certification and education. Retrieved from Adams, A. S., Soumera, S. B., Lomas, J., & Ross-Degnan, D. (1999). Evidence of self-report bias in assessing adherence to guidelines. International Journal for Quality in Health Care, Ajzen, I. (1991). The theory of planned behavior. Organizational behavior and Human Decision Process, 50(2), doi: / (91) Eastman, P. (2014, April 10). ASCO report on state of U.S. cancer care identifies perfect storm of challenges. Oncology Times, 36(7), 1, 12. Faul, F., Erdfelder, E., Buchner, A., & Lang, A. G. (2009). Statistical power analysis using G*Power 3.1Tests for correlation and regression analysis. Behavior Research Methods, 41(4), doi: /BRM Green, B. B., & Coronado, G. D. (2014). BeneFITS to increase colorectal cancer screening in priority populations. JAMA Internal Medicine, 174(8), doi: /jamainternmed Hubbard, J. M., & Grothy, A. (2013, October). Adolescent and young adult colorectal cancer. Journal of the National Comprehensive Cancer Network, 11(10), Kaplowitz, M. D., Hadlock, T. D., & Levine, R. (2004). A comparison of web and mail survey response rates. Public Opinion Quarterly, 68(1), doi: /poq/nfh006 Kelly, P. P. (2011). Colorectal cancer family history assessment Documentation deficiencies and future directions. Clinical Journal of Oncology Nursing, 15(5), E75-E82. doi: /11.cjon.e75-e82

38 References Mosen, D. M., Feldstein, A. C., Perrin, N. A., Rosales, A. G., Smith, D. H., Liles, E. G., Elston-Lafata, J. (2013). More comprehensive discussion of CRC screening associated with higher screening. American Journal of Managed Care, 19(4), Retrieved from Polansky, M., Ross, A. C., Coniglio, D., Garino, A., & Hudmon, K. S. (2014). Cancer education in physician assistant programs. The Journal of Physician Assistant Education, 25(1), Power, E., Miles, A., Von Wagner, C., Robb, K., & Wardle, J. (2009). Uptake of colorectal cancer screening System provider and individual factors and strategies to improve participation. Future Oncology, 18, 1371.doi: /fon Qualtrics (Version 12018) [Computer software]. (2014). Schwaiger, C. B., Aruda, M. A., LaCousiere, S., Lynch, K. E., & Rubin, R. J. (2013, September). Increasing adherence to national cervical cancer guidelines. The Journal for Nurse Practitioners, 9(8), doi: /j.nurpra Siegel, R. L., Miller, K. D., & Jemal, A. (2015). Projected new cases and death rates CA: A Cancer Journal for Clinicians, 65(1), Spruce, L. R., & Sanford, J. T. (2012). An intervention to change the approach to colorectal cancer screening in primary care. Journal of the American Academy of Nurse Practitioners, 24, doi: /j x Yarbroff, K. R., Mariotto, A. B., Feuer, E., & Brown, M. L. (2008). Projections of the costs associated with colorectal cancer care in the United States Health Economics, 17, 947. doi: /hec.1307 Winawer, S., Fletcher, R., Rex, D., Bond, J., Burt, R., Ferucci, J. Semmang, C. (2003, February). Colorectal cancer screening and surveillance Clinical guidelines and rationale Update based on new evidence. Gastroenterology, 124,