Low Literacy Intervention for Colorectal Cancer Screening
Charles L. Bennett MD PhD MPP
Jesse Brown VAMC (Lakeside CBOC)
Chicago, IL
Funding Period: May 2000 - April 2003

BACKGROUND/RATIONALE:
Of 17 performance measures of hospital quality regularly reported for the Veterans Administration (VA) health care system, rates of colorectal cancer screening are the lowest.

OBJECTIVE(S):
The objectives of this study were to 1) test whether a health care provider-directed intervention increased colorectal cancer screening rates in an urban VA medical center and 2) evaluate the cost-effectiveness of the intervention.

METHODS:
The study was a randomized controlled trial, conducted at two clinic firms at a VA Medical Center in Chicago. Eligible patients were men, age 50 and older, had no personal or family history of colorectal cancer or polyps, had not received colorectal cancer screening, and had at least one visit to the clinic during the study period. Health care providers in the intervention firm attended a workshop on colorectal cancer screening. Every 4-6 months they attended quality improvement workshops where they received group screening rates, individualized confidential feedback, and training on improving communication with patients with limited literacy skills. Medical records were reviewed for colorectal cancer screening recommendations and completion. Literacy level was assessed in a subset of patients. In the cost-effectiveness analysis, resource and cost estimates were derived.

FINDINGS/RESULTS:
Among 1978 Veterans included in the study, colorectal cancer screening was recommended for 76.0% of patients in the intervention firm and for 69.4% of controls (p=0.02). Screening tests were completed by 41.3% of patients in the intervention group versus 32.4% of controls (p=0.003). Rates of colorectal screening for the intervention versus control arm were 41.3% versus 32.4%. The cost of the feedback program based on data reports generated from manual review of medical records was $86,753, and the incremental cost-effectiveness ratio was $978 per additional Veteran screened. However, if quarterly feedback data reports could be generated directly by information technology systems, the cost estimates decreased to $17,341 and $196, respectively.

IMPACT:
Studies have shown that adults with low education levels and low-income suffer disproportionately high levels of cancer incidence, advanced cancers at presentation and mortality, and are less likely to be screened for cancer. VA has identified low literacy as a significant problem among its patient population and a priority area for research. The project will help identify the colorectal cancer screening information needs of patients with limited literacy skills and will develop and test the efficacy of colorectal cancer screening education programs specifically designed for these patients and their MDs. The results of this study will provide a foundation for future interventions designed for low socioeconomic status and minority populations.
Low literacy is associated with poorer knowledge and more negative attitudes toward CRC screening and may be an overlooked screening barrier. This intervention, targeted to men with low literacy, significantly increased CRC screening among Veterans, especially those with inadequate literacy.

PUBLICATIONS:

Journal Articles

1. Fitzgibbon ML, Ferreira MR, Dolan NC, Davis TC, Rademaker AW, Wolf MS, Liu D, Gorby N, Schmitt BP, Bennett CL. Process evaluation in an intervention designed to improve rates of colorectal cancer screening in a VA medical center. Health Promotion Practice. 2007; 8(3): 273-81.
2. Wolf MS, Bennett CL. Local perspective of the impact of the HIPAA privacy rule on research. Cancer. 2006; 106(2): 474-9.
3. Dolan NC, Ferreira MR, Fitzgibbon ML, Davis TC, Rademaker AW, Liu D, Lee J, Wolf M, Schmitt BP, Bennett CL. Colorectal cancer screening among African-American and white male veterans. American Journal of Preventive Medicine. 2005; 28(5): 479-82.
4. Ferreira MR, Dolan NC, Fitzgibbon ML, Davis TC, Gorby N, Ladewski L, Liu D, Rademaker AW, Medio F, Schmitt BP, Bennett CL. Health care provider-directed intervention to increase colorectal cancer screening among veterans: results of a randomized controlled trial. Journal of Clinical Oncology. 2005; 23(7): 1548-54.
5. Dolan NC, Ferreira MR, Davis TC, Fitzgibbon ML, Rademaker A, Liu D, Schmitt BP, Gorby N, Wolf M, Bennett CL. Colorectal cancer screening knowledge, attitudes, and beliefs among veterans: does literacy make a difference? Journal of Clinical Oncology. 2004; 22(13): 2617-22.
6. Ferreira MR, Dolan NC, Fitzgibbon M, Newlin R, Davis TC, Rademaker A, Schmitt B, Medio F, Bennet CL. An Intervention to Increase Colorectal Cancer Screening Among Veterans: Rationale and Study Design. International Journal of Cancer Prevention. 2004; 1: 369-381.
7. Golub RM, Bennett CL, Stinson T, Venta L, Morrow M. Cost minimization study of image-guided core biopsy versus surgical excisional biopsy for women with abnormal mammograms. Journal of Clinical Oncology. 2004; 22(12): 2430-7.
8. Davis TC, Dolan NC, Ferreira MR, Tomori C, Green KW, Sipler AM, Bennett CL. The role of inadequate health literacy skills in colorectal cancer screening. Cancer Investigation. 2001; 19(2): 193-200.

DRA: Chronic Diseases, Health Services and Systems, Special (Underserved, High Risk) Populations
DRE: Communication and Decision Making, Prevention, Quality of Care
Keywords: Education (patient), Screening
MeSH Terms: none