Testing to prevent colon cancer: results from a rural community intervention.

PURPOSE: Colon cancer is the second leading cause of cancer death in the United States. Despite tests that can detect and enable removal of precancerous polyps, effectively preventing this disease, screening for colon cancer lags behind other cancer screening. The purpose of this study was to develop and test a community-based participatory approach to increase colon cancer screening. METHODS: Using a community-based participatory research approach, the High Plains Research Network and their Community Advisory Council developed a multicomponent intervention-Testing to Prevent Colon Cancer-to increase colon cancer screening. A controlled trial compared 9 intervention counties in northeast Colorado with 7 control counties in southeast Colorado. We performed a baseline and postintervention random digit-dial telephone survey and conducted both intent-to-treat and on-treatment analyses. RESULTS: In all, 1,050 community members completed a preintervention questionnaire and 1,048 completed a postintervention questionnaire. During the study period, there was a 5% absolute increase in the proportion of respondents who reported ever having had any test in the intervention region (from 76% to 81%) compared with no increase in the control region (77% at both time points) (P = .22). No significant differences between these groups were found in terms of being up to date generally or on specific tests. The extent of exposure to intervention materials was associated with a significant and cumulative increase in screening. CONCLUSIONS: This community-based multicomponent intervention engaged hundreds of community members in wide dissemination aimed at increasing colorectal cancer screening. Although we did not find any statistically significant differences, the findings are consistent with an intervention-related increase in screening and provide preliminary evidence on the effectiveness of such interventions to improve colon cancer screening.

Testing to prevent colon cancer: how rural community members took on a community-based intervention.

Participatory research can elevate research relevance and effectiveness. The literature contains few first-hand descriptions of community members engaged in research. In 2003, the High Plains Research Network convened a Community Advisory Council (CAC) that quickly began providing input, feedback, innovation, and dissemination efforts. After receiving a participatory research grant from the Centers for Disease Control and Prevention aimed at increasing colorectal cancer screening, the CAC participated in an intensive training on colon cancer prevention and spent 6 months developing a locally relevant intervention-Testing to Prevent Colon Cancer. CAC members participated in all aspects of the research including intervention messaging, survey design, recruitment, implementation, analysis and interpretation of data, and dissemination of results including presentations at national venues and coauthoring manuscripts. Our experience attests to the power of participatory research in efforts to improve health outcomes.

Card studies for observational research in practice.

PURPOSE: Observational studies that collect patient-level survey data at the point-of-care are often called card studies. Card studies have been used to describe clinical problems, management, and outcomes in primary care for more than 30 years. In this article we describe 2 types of card studies and the methods for conducting them. METHODS: We undertook a descriptive review of card studies conducted in 3 Colorado practice-based research networks and several other networks throughout the United States. We summarized experiences of the State Networks of Colorado Ambulatory Practices and Partners (SNOCAP). RESULTS: Card studies can be designed to study specific conditions or care (clinicians complete a card when they encounter patients who meet inclusion criteria) and to determine trends and prevalence of conditions (clinicians complete a card on all patients seen during a period). Data can be collected from clinicians and patients and can be linked. CONCLUSIONS: Card studies provide cross-sectional descriptive data about clinical care, knowledge and behavior, perception of care, and prevalence of conditions. Card studies remain a robust method for describing primary care.

Rural community members' perceptions of harm from medical mistakes: a High Plains Research Network (HPRN) Study.

OBJECTIVE: The aim of this study was to learn about community members' definitions and types of harm from medical mistakes. METHODS: Mixed methods study using community-based participatory research (CBPR). The High Plains Research Network (HPRN) with its Community Advisory Council (CAC) designed and distributed an anonymous survey through local community newspapers. Survey included open-ended questions on patients' experiences with medical mistakes and resultant harm. Qualitative analysis was performed by CAC and research team members on mistake descriptions and types of reported harm. Patient Safety Taxonomy coding was performed on a subset of surveys that contained actual medical errors. RESULTS: A total of 286 surveys were returned, with 172 respondents (60%) reporting a total of 180 perceived medical mistakes. Quantitative analysis showed that 41% of perceived mistakes (n = 73) involved only unanticipated outcomes. Reported types of harm included emotional, financial, and physical harm. Reports suggest that perceived clinician indifference to unanticipated outcomes may lead to patients' loss of trust and belief that the unexpected outcome was a result of an error. DISCUSSION: CBPR methodology is an important strategy to design and implement a community-based survey. Community members reported experiencing medical mistakes, most with harmful outcomes. The response they received by the medical community may have influenced their perception of mistake and harm.

Action or inaction? Decision making in patients with diabetes and elevated blood pressure in primary care.

OBJECTIVE: Hypertension increases micro- and macrovascular complications of diabetes. The goal for blood pressure is <130/80 mmHg. In primary care, however, blood pressure in many patients exceeds this goal. In this study, we evaluated the clinical decision-making process when a patient with diabetes presents with elevated blood pressure. RESEARCH DESIGN AND METHODS: Twenty-six primary care practices in two practice-based research networks in Colorado participated. Questionnaires were completed after each encounter with an adult with type 2 diabetes. Data obtained from the survey included 1) demographic information, 2) blood pressure results, 3) action taken, 4) type of action if action was taken, and 5) reasons for inaction if action was not taken. Bivariate and multivariate analyses were performed to identify predictors of action. RESULTS: Completed surveys totaled 778. Blood pressure was 130/74 +/- 18.8/12.0 mmHg (mean +/- SD). Sixty-two percent of patients exceeded goals. Action was taken to lower blood pressure in 34.9% of those. Predictors of action were 1) blood pressure level, 2) total number of medicines the patient was taking, and 3) patient already taking medicines for blood pressure. As blood pressure rose, providers attributed inaction more often to "competing demands" and reasons other than "blood pressure being at or near goal." CONCLUSIONS: No evidence was found for patterns of poor care among primary care physicians. Providers balance the clinical circumstances, including how elevated the blood pressure is, and issues of polypharmacy, medication side effects, and costs when determining the best course of action. Knowledge deficit is not a common cause of inaction.

Barriers to quality care for dying patients in rural communities.

CONTEXT: Barriers to providing optimal palliative care in rural communities are not well understood. PURPOSE: To identify health care personnel's perceptions of the care provided to dying patients in rural Kansas and Colorado and to identify barriers to providing optimal care. METHODS: An anonymous self-administered survey was sent to health care personnel throughout 2 rural practice-based research networks. Targeted personnel included clinicians, nurses, medical assistants, chaplains, social workers, administrators, and ancillary staff, who worked at hospice organizations, hospitals, ambulatory clinics, public health agencies, home health agencies, and nursing homes. FINDINGS: Results from 363 completed surveys indicated that most health care personnel were satisfied with the palliative care being provided in their health care facilities (84%) and that most were comfortable helping dying patients transition from a curative to a palliative focus of care (87%). Yet, many reported that the palliative care provided could be improved and many reported that family members' avoidance of issues around dying (60%) was a barrier to providing optimal care in rural health care facilities. CONCLUSIONS: Findings suggest that health care personnel perceive they are effective at providing palliative care in their rural health care facilities, yet face barriers to providing optimal end-of-life care. Results of this study suggest that differences in training and experience may influence health care personnel's perceptions of the existing barriers. It may be important in rural areas to customize interventions to both the professional role and the site of care.

Triage and diagnosis of chest pain in rural hospitals: implementation of the ACI-TIPI in the High Plains Research Network.

PURPOSE: The Acute Cardiac Ischemia Time-Insensitive Predictive Instrument (ACI-TIPI) has been shown to improve diagnostic accuracy of acute cardiac ischemia (ACI) and decrease coronary care unit admissions in urban emergency departments. The purpose of this study was to determine the impact of the ACI-TIPI on triage and diagnosis of patients with chest pain in rural hospitals. METHODS: We undertook a controlled trial of the impact ACI-TIPI use in the High Plains Research Network (HPRN). Main outcome measures were the triage of patients in emergency departments (admission, transfer, or discharge home) and diagnostic accuracy. RESULTS: There were 1,861 patients seen during a 10-month period. Forty-five percent of all patients complaining of chest pain were discharged home from the emergency department. Eight percent were transferred from the emergency department, and another 10% were transferred later after admission. Among patients with acute myocardial infarction or unstable angina, 22.2% were transferred directly from the emergency department and only 3% were discharged home when ACI-TIPI was available, compared with 18.7% transferred and 5.2% discharged home when not available (P = .4). Diagnostic accuracy was high and not statistically different with the addition of the ACI-TIPI score (86.8% ACI-TIPI off vs 89.0% ACI-TIPI on, P = .15), CONCLUSIONS: Physicians in the HPRN provided appropriate diagnosis and triage to patients with chest pain. Routine addition of the ACI-TIPI score did not improve diagnostic accuracy or significantly change triage. Further research on ACI-TIPI in rural hospitals is necessary before recommending routine use of the ACI-TIPI.

Missing clinical information during primary care visits.

CONTEXT: The coordinating function of primary care is information-intensive and may be impeded by missing clinical information. However, missing clinical information has not been explicitly investigated in the primary care setting. OBJECTIVE: To describe primary care clinicians' reports of missing clinical information. DESIGN, SETTING, AND PARTICIPANTS: Cross-sectional survey conducted in 32 primary care clinics within State Networks of Colorado Ambulatory Practices and Partners (SNOCAP), a consortium of practice-based research networks participating in the Applied Strategies for Improving Patient Safety medical error reporting study. Two hundred fifty-three clinicians were surveyed about 1614 patient visits between May and December 2003. For every visit during 1 half-day session, each clinician completed a questionnaire about patient and visit characteristics and stated whether important clinical information had been missing. Clinician characteristics were also recorded. MAIN OUTCOME MEASURES: Reports of missing clinical information frequency, type, and presumed location; perceived likelihood of adverse effects, delays in care, and additional services; and time spent looking for missing information. Multivariate analysis was conducted to assess the relationship of missing information to patient, visit, or clinician characteristics, adjusting for potential confounders and effects of clustering. RESULTS: Clinicians reported missing clinical information in 13.6% of visits; missing information included laboratory results (6.1% of all visits), letters/dictation (5.4%), radiology results (3.8%), history and physical examination (3.7%), and medications (3.2%). Missing clinical information was frequently reported to be located outside their clinical system but within the United States (52.3%), to be at least somewhat likely to adversely affect patients (44%), and to potentially result in delayed care or additional services (59.5%). Significant time was reportedly spent unsuccessfully searching for missing clinical information (5-10 minutes, 25.6%; >10 minutes, 10.4%). After adjustment, reported missing clinical information was more likely when patients were recent immigrants (odds ratio [OR], 1.78; 95% confidence interval [CI], 1.06-2.99), new patients (OR, 2.39; 95% CI, 1.70-3.35), or had multiple medical problems compared with no problems (1 problem: OR, 1.09; 95% CI, 0.69-1.73; 2-5 problems: OR, 1.87; 95% CI, 1.21-2.89; >5 problems: OR, 2.78; 95% CI, 1.61-4.80). Missing clinical information was less likely in rural practices (OR, 0.52; 95% CI, 0.29-0.92) and when individual clinicians reported having full electronic records (OR, 0.40; 95% CI, 0.17-0.94). CONCLUSIONS: Primary care clinicians report that missing clinical information is common, multifaceted, likely to consume time and other resources, and may adversely affect patients. Additional research on missing information is needed to focus on validating clinicians' perceptions and on conducting prospective studies of its causes and sequelae.