Assessing the impact of the 2018 National Health and Medical Research Council polyp surveillance guidelines on compliance with surveillance intervals at two public hospitals.

BACKGROUND: Several studies have highlighted poor compliance with surveillance colonoscopy guidelines. The National Health and Medical Research Council (NHMRC) guidelines were revised in 2018 and were more complex than the previous iteration (2011). The aim of this study was to determine the impact of 2018 NHMRC polyp surveillance guidelines on compliance with colonoscopy surveillance intervals. METHODS: A multicentre retrospective clinical audit was conducted between January 2020 and February 2021. Patients awaiting a colonoscopy for polyp surveillance at two public tertiary care hospitals in South Australia were included. Compliance rates of recommended polyp surveillance colonoscopy intervals after implementation of 2018 NHMRC guidelines were compared with 2011 NHMRC guidelines. The projected impact on colonoscopy bookings of the change in guideline intervals was modelled to 5 and 10 years, factoring in differences in compliance. RESULTS: Of 3996 patients awaiting colonoscopy services at two public hospitals in South Australia, 1984 patients (60% male, median age 61 years) were waitlisted for polyp surveillance. Overall compliance with surveillance guidelines was >60%. Implementation of the 2018 NHMRC guidelines significantly reduced compliance from 65.8% (2011 guidelines) to 50.8% (2018) (χ2 <0.001, OR 0.5). Modelling projections to 5 and 10 years demonstrated that application of the 2018 guidelines significantly increases the projected number of colonoscopy bookings per year. CONCLUSION: The revised 2018 NHMRC guidelines have resulted in significantly poorer compliance post-implementation, possibly due to their increased complexity. This has potential to increase the surveillance colonoscopy waiting list burden.

General practice perspectives on a bowel cancer screening quality improvement intervention using the Consolidated Framework for Implementation Research.

INTRODUCTION: An understanding of contextual factors that influence whether general practitioners advise their patients to be screened for colorectal cancer (CRC) might guide interventions to increase screening participation from its persistently low rate. We report on the use of a theory-based tool to explore contextual factors that might influence implementation of a novel quality improvement (QI) intervention to increase CRC screening in general practice (CRC-QI). The objective was to identify and incorporate strategies into the intervention that will enable flexible implementation across different practice settings. STUDY TYPE: A qualitative study to explore contextual facilitators of, and barriers to, the implementation of a novel CRC-QI intervention. METHODS: Eighteen staff, from three self-nominated general practices, participated in focus group discussions. The Consolidated Framework for Implementation Research (CFIR), which included constructs relevant to CRC screening in primary care, guided the formative evaluation. Findings were aligned to the CFIR model using a deductive thematic analysis. RESULTS: Contextual facilitators of, and barriers to, the implementation of the CRC-QI intervention were identified in each CFIR domain and CRC-relevant construct. Five consistent themes were identified that potentially influence elements of the CRC-QI intervention: priority setting and incentives, information technology, patient-level barriers, clinical practice, and the National Bowel Cancer Screening Program (NBCSP). Participants proposed that incentive payments and NBCSP policy changes (outer-setting strategies) would facilitate organisational change (inner-setting strategies) and the effective implementation of the CRC-QI intervention. CONCLUSION: There may be an opportunity to better engage general practice in CRC screening via outer-setting constructs that support existing clinical practice. For example, improvements to the National Cancer Screening Register and Quality Improvement Incentive - Practice Incentives Program (PIP) could be made without altering the NBCSP design.

Engagement of General Practice in an Australian Organised Bowel Cancer Screening Program: A Cross-Sectional Survey of Knowledge and Practice.

BACKGROUND: Understanding factors causing variation in family physicians/general practitioners (GPs) screening knowledge, understanding and support of organised population-based colorectal cancer (CRC) programs can direct interventions that maximise the influence of a CRC screening recommendation from a GP. This study aims to assess contextual factors that influence knowledge and quality improvement (QI) practice directed to CRC screening in Australian general practice. METHODS: A convenience sample of anonymous general practice staff from all Australian states and territories completed a web-based survey. Multivariate analyses assessed the association between CRC screening knowledge and QI-CRC practice scores and patient, organisational and environmental-level contextual factors.  Results: Of 1,013 survey starts, 918 respondents (90.6%) completed the survey. Respondents less likely to recommend FOBT screening had lower knowledge and QI practice scores directed to CRC screening. Controlling for individual and practice characteristics, respondents' rating of the Australian National Bowel Cancer Screening Program (NBCSP) support for preventive care, attending external education, and sufficient practice resources to implement QI practice (generally) were the strongest factors associated with QI practice directed towards CRC screening. Knowledge scores were less amenable to the influence of contextual factors explored. CONCLUSION: More active engagement of family medicine/general practice to improve screening promotion could be achieved through better QI resourcing without changing the fundamental design of population-based CRC screening programs.

From participation to diagnostic assessment: a systematic scoping review of the role of the primary healthcare sector in the National Bowel Cancer Screening Program.

Primary health care (PHC) plays a vital support role in organised colorectal cancer (CRC) screening programs by encouraging patient participation and ensuring timely referral for diagnostic assessment follow up. A systematic scoping review of the current evidence was conducted to inform strategies that better engage the PHC sector in organised CRC screening programs. Articles published from 2005 to November 2019 were searched across five databases. Evidence was synthesised and interventions that specifically require PHC involvement were mapped to stages of the CRC screening pathway. Fifty-seven unique studies were identified in which patient, provider and system-level interventions align with defined stages of the CRC screening pathway: namely, identifying/reminding patients who have not responded to CRC screening (non-adherence) (n=46) and follow up of a positive screen referral (n=11). Self-management support initiatives (patient level) and improvement initiatives (system level) demonstrate consistent benefits along the CRC screening pathway. Interventions evaluated as part of a quality-improvement process tended to report effectiveness; however, the variation in reporting makes it difficult to determine which elements contributed to the overall study outcomes. To maximise the benefits of population-based screening programs, better integration into existing primary care services can be achieved through targeting preventive and quality care interventions along the entire screening pathway.

Improving Australian National Bowel Cancer Screening Program outcomes through increased participation and cost-effective investment.

BACKGROUND: The Australian National Bowel Cancer Screening Program (NBCSP) provides biennial immunochemical faecal occult blood test (iFOBT) screening for people aged 50-74 years. Previous work has quantified the number of colorectal cancer (CRC) deaths prevented by the NBCSP and has shown that it is cost-effective. With a 40% screening participation rate, the NBCSP is currently underutilised and could be improved by increasing program participation, but the maximum appropriate level of spending on effective interventions to increase adherence has not yet been quantified. OBJECTIVES: To estimate (i) reductions in CRC cases and deaths for 2020-2040 attributable to, and (ii) the threshold for cost-effective investment (TCEI) in, effective future interventions to improve participation in the NBCSP. METHODS: A comprehensive microsimulation model, Policy1-Bowel, was used to simulate CRC natural history and screening in Australia, considering currently reported NBCSP adherence rates, i.e. iFOBT participation (∼40%) and diagnostic colonoscopy assessment rates (∼70%). Australian residents aged 40-74 were modelled. We evaluated three scenarios: (1) diagnostic colonoscopy assessment increasing to 90%; (2) iFOBT screening participation increasing to 60% by 2020, 70% by 2030 with diagnostic assessment rates of 90%; and (3) iFOBT screening increasing to 90% by 2020 with diagnostic assessment rates of 90%. In each scenario, we estimated CRC incidence and mortality, colonoscopies, costs, and TCEI given indicative willingness-to-pay thresholds of AUD$10,000-$30,000/LYS. RESULTS: By 2040, age-standardised CRC incidence and mortality rates could be reduced from 46.2 and 13.5 per 100,000 persons, respectively, if current participation rates continued, to (1) 44.0 and 12.7, (2) 36.8 and 8.8, and (3) 31.9 and 6.5. In Scenario 2, 23,000 lives would be saved from 2020-2040 vs current participation rates. The estimated scenario-specific TCEI (Australian dollars or AUD$/year) to invest in interventions to increase participation, given a conservative willingness-to-pay threshold of AUD$10,000/LYS, was (1) AUD$14.9M, (2) AUD$72.0M, and (3) AUD$76.5M. CONCLUSION: Significant investment in evidence-based interventions could be used to improve NBCSP adherence and help realise the program's potential. Such interventions might include mass media campaigns to increase program participation, educational or awareness interventions for practitioners, and/or interventions resulting in improvements in referral pathways. Any set of interventions which achieves at least 70% iFOBT screening participation and a 90% diagnostic assessment rate while costing under AUD$72 million annually would be highly cost-effective (

A systematic scoping review of determinants of multidisciplinary cancer team access and decision-making in the management of older patients diagnosed with colorectal cancer.

Early diagnosis of colorectal cancer (CRC) and access to optimal treatment achieves optimal cancer outcomes. However, CRC survival inequalities persist with a lower survival rate for older patients (≥65 years). Although the reasons for poorer cancer survival in older people are complex, evidence suggests that these patients are less likely to receive best practice care as indicated by access to multidisciplinary team (MDT) care. Three electronic databases were systematically searched to examine factors that affect access to, and clinical decision-making, in the context of MDT care of older people with CRC. We included studies reporting empirical data relating to predictors for a patient's case being discussed at a MDT meeting and/or factors that impact treatment decision-making during the meeting. From 303 returned titles and abstracts, eighteen articles were reviewed. Eight studies specifically selected older patients, with eligibility criteria varying from ≥65 to ≥80 years. Five articles explored predictors of MDT access, with all articles identifying age as a negative, and advanced stage as a positive predictor of MDT discussion. Fourteen studies explored factors that influenced the MDT decision-making process, with older age and presence of comorbid disease negatively influencing treatment decisions (cases less often discussed and/or treatment not recommended). A few studies identified access to a MDT discussion as an independent predictor for CRC treatment. Access to the MDT process for older patients with a CRC diagnosis should be based on relevant geriatric domains rather than on chronological age alone, which is expected to allow more appropriate clinical decision-making and reduce treatment inequities for older patients with cancer.

Engaging primary healthcare nurses in men's health education: A pilot study.

Many countries have identified a need for targeted men's health promotion within primary health care as part of broader men's health policy. Primary health care nurses are well placed to deliver such services but may lack the requisite skills. The aim of this study was to pilot the delivery phase of an education program and evaluate a train-the-trainer approach for delivering men's health education to primary health care nurses. The 8-h train-the-trainer workshop was designed to equip nurses to deliver men's health education workshops to peers. Surveys of facilitators (n = 18) and peer workshop participants (n = 98) evaluated their level of confidence in men's health and knowledge and skills in men's health promotion. After completing the train-the-trainer workshop, most facilitators expressed confidence (92%), and all indicated sufficient knowledge and access to resources to deliver a peer workshop. All agreed that the module was sufficiently flexible to suit their local setting. Following the peer education workshop, facilitators and workshop participants reported high levels of confidence and knowledge in men's health promotion. This pilot evaluation suggests train-the-trainer is an effective model to deliver men's health education across a range of settings, with a flexible approach to raising awareness and improving the skills of primary health care nurses in men's health promotion.

"Men's health--a little in the shadow": a formative evaluation of medical curriculum enhancement with men's health teaching and learning.

BACKGROUND: Enhancing a medical school curriculum with new men's health teaching and learning requires an understanding of the local capacity and the facilitators and barriers to implementing new content, and an approach that accommodates the systemic and cultural differences between medical schools. METHODS: A formative evaluation was undertaken to determine the perspectives of key informants (academics, curriculum developers) from four Australian medical schools about the strategies needed to enhance their curriculum with men's health teaching and learning. Through semi-structured questioning with 17 key informants, interviewees also described the contextual barriers and facilitators to incorporating new topic areas into existing curriculum. Interviews were recorded with consent, transcribed verbatim, and analysed by two researchers to identify key themes. RESULTS: Interviewees were enthusiastic about incorporating men's health content through a men's health curriculum framework but highlighted the need for systems to assist in identifying gaps in their current curriculum where the men's health topics could be integrated. The student experience was identified as a key driver for men's health teaching and learning. Furthermore, core men's health clinical outcomes needed to be defined and topic areas vertically integrated across the curricula. This would ensure that students were appropriately equipped with the skills and knowledge for subsequent clinical practice in a range of geographical settings. Interviewees consistently suggested that the best implementation strategy is to have someone 'on the ground' to work directly with medical school staff and champion the men's health discipline. Providing mechanisms for sharing knowledge and resources across medical schools was highlighted to facilitate implementation, particularly for those medical schools with limited men's health teaching resources. CONCLUSIONS: Despite the unanimous support for men's health teaching and learning, the evaluation highlighted that the student experience must be recognised as paramount when integrating new topic areas into an already packed curriculum. A community of practice, where medical schools share relevant resources and knowledge, could help to ensure a commonality of student experience with respect to men's health learning in medical schools across different geographical settings and with different levels of resourcing. Such an approach could also be adapted to other areas of curriculum enhancement.

The correlates of chronic disease-related health literacy and its components among men: a systematic review.

BACKGROUND: Chronic diseases drive the burden of disease in many societies, particularly among men. Lifestyle behaviours are strongly associated with chronic disease development, and in a number of countries men tend to engage in more risky behaviours, and have lower health knowledge and attention to prevention, than women. This study investigated the correlates of men's health literacy and its components about major lifestyle-related diseases, namely ischaemic heart disease and type 2 diabetes mellitus, to gain evidence to guide the development of policy and programs to improve men's health. METHODS: A systematic review was undertaken of observational studies that investigated men's health literacy and its components related to ischaemic heart disease or type 2 diabetes mellitus, and their associated risk factors. The Cumulative Index to Nursing and Allied Health Literature (CINAHL), MEDLINE, PsycINFO, Embase and the Cochrane Library databases were searched for articles published since 2003. The strength of the evidence was rated using the GRADE approach. RESULTS: After screening and review of 504 articles, the search elicited nine studies for inclusion: only one study examined health literacy (nutrition literacy). The majority of included studies focused on only one component of health literacy, namely knowledge (n = 7) and personal skills (confidence) (n = 1). Twenty correlates were identified, primarily relating to the knowledge component, with the strength of the evidence for only one correlate, education, graded as being of moderate quality. The evidence for all other correlates was graded as being of low quality. CONCLUSIONS: The limited body of research identified may have resulted from a lack of consensus about the definition of health literacy, and a concordant set of validated health literacy measures. Despite these limitations, broadening the search to include components of health literacy has identified that several factors are associated with men's knowledge and awareness of ischaemic heart disease and type 2 diabetes mellitus that will assist in the development of men's health promotion strategies. However, addressing the broader knowledge gaps and controversy in the health literacy field will deliver policy and program benefits to address these major contributors to the burden of disease among men.