Patients are more likely to be screened for colorectal cancer if it is recommended by a health care provider. Therefore, it is imperative that providers have access to the latest screening guidelines.
This practice-based project sought to identify Kentucky primary care providers’ preferred sources and methods of receiving colorectal cancer information to improve state comprehensive cancer control provider outreach initiatives.
Four focus groups were conducted with primary care physicians, nurse practitioners, and physician assistants. Discussion included preferred sources and methods of receiving updated screening guidelines, legislation, and statewide public awareness campaign materials.
Providers (
When delivering colorectal cancer information to primary care providers, multiple approaches are needed. An ideal partner for dissemination of information is state comprehensive cancer control coalitions, considering their prioritization of colorectal cancer screening and existing networks of partners who were identified as trusted sources.
Assessment of primary care providers’ preferred methods and sources of receiving colorectal cancer information informs strategies for practice among comprehensive cancer control coalitions.
Colorectal cancer is the second leading cause of cancer incidence and mortality among men and women combined in the United States.
The importance of colorectal cancer screening in reducing incidence, morbidity and death from the disease has been well established.
In light of this research, it is essential that providers have access to the most accurate, up-to-date information on colorectal cancer in order to make appropriate screening recommendations, as well as engage in shared decision making with the patient regarding screening test options. This information should include: clinical screening guidelines for normal and at-risk populations; the benefits and limitations of established procedures as well as new technologies; knowledge of colorectal cancer public awareness campaigns; referral processes for free or low-cost screening programs; and news of any recent colorectal cancer-related legislation. Further, establishing ideal methods for learning about colorectal cancer information, identifying trusted sources and determining the frequency of such information is needed.
The Kentucky Cancer Consortium (KCC), Kentucky’s statewide comprehensive cancer control coalition, received colorectal cancer supplemental funding from the Centers for Disease Control and Prevention’s (CDC) Division of Cancer, Comprehensive Cancer Control Branch to be used for implementation of strategies identified in the Kentucky Cancer Action Plan.
KCC asked healthcare provider partner organizations involved in statewide comprehensive cancer control (i.e., Kentucky Medical Association, Kentucky Health Care Improvement Authority, Centers for Rural Health, Kentucky Ambulatory Network, Kentucky Academy of Family Physicians, Area Health Education Centers) to assist with recruitment and local focus group logistics. These organizations, which serve physicians, physician assistants and nurse practitioners, are utilized by the provider community for conferences, publications, continuing medical credit, medical education, practice guidelines, and opportunities to participate in research.
KCC developed a one-page flyer for the three partners that was tailored with local contact information and logistics, and was distributed by the partner organizations via e-mail listservs, postal mail, and clinic mailboxes to their constituents and colleagues. As a result of the local partners’ recruitment efforts, four regional focus groups spanning the state of Kentucky were conducted in May-June 2009. Participants were compensated with a $150 monetary gift. Each session lasted approximately 1.5 hours and participants traveled an average of 34 miles roundtrip to attend the focus groups.
After participants completed a brief demographic survey, the moderator, who was the same for all groups, initiated discussion by describing the overall purpose of the focus groups; presenting an overview of colorectal cancer disparities in Kentucky using the state cancer registry’s 2008 special report on colorectal cancer;
In addition to attending and moderating the actual focus groups, all three authors independently reviewed and analyzed the focus group notes in order to extract descriptive, thematic information related to primary care providers’ preferences for receiving colorectal cancer-related information. The results reported herein were refined through an iterative process of discussion, debate and consensus among the investigative team.
In sum, 17 primary care providers participated in the four focus groups (
All providers interviewed expressed a great deal of interest in receiving colorectal cancer prevention and screening guidelines, legislative updates and resources related to public awareness campaigns. There was overall agreement within and among focus groups and provider types on preferred methods of dissemination as well as trusted sources. Participants were familiar with the recently revised colorectal cancer screening guidelines; however, none of the respondents had seen the Kentucky Cancer Registry’s 2008 special report on colorectal cancer or knew that legislation had passed in Kentucky creating a colorectal cancer screening program and an insurance coverage mandate.
Regardless of topic—new colorectal prevention and screening information, legislative updates, or public awareness campaigns – the preferred methods of receiving this information were uniform. Collectively, providers’ preferred methods were:
E-mail from trusted sources Scientific journals Regional and/or statewide professional conferences Media
Respondents emphasized the fact that although e-mail was one of the most preferred methods of communication, if it is sent from an unknown source or entity, it may be ignored or discarded due to the large volume of e-mails they receive. The participants emphasized the importance of e-mails coming from known and trusted sources so that they would pay attention to the content and information. Providers suggested that e-mails be delivered immediately following the announcement (e.g., guideline changes, legislation), and followed-up with periodic reminder e-mails. Providers indicated the preferred frequency of e-mails as once per month and noted that the content of the email should include a brief description of the topic at hand and a web link to more detailed information. E-mail was favored due to its perceived cost effectiveness and timeliness. Further, providers emphasized the need to receive news prior to the public in order to be prepared for subsequent questions from their patients. Preferred scientific journals were those that focused on primary care providers and their practice. The journals specifically mentioned in relation to colorectal cancer screening guidelines were:
In addition to scientific journals and web-based clinical resources, the providers encouraged adding new colorectal cancer information to agendas at both regional and statewide professional conferences. While participants stated that they most often attend their own professional organization’s conferences, the most appealing conferences provide continuing education and have low registration fees. Respondents noted that the provider’s attention is more focused at a conference than in his/her busy office practice. Providers specifically called for expert speakers to travel to their area of the state which may be geographically isolated, such as the Appalachian Mountains or far western Kentucky, saving them a six to ten hour roundtrip drive to Louisville or Lexington and lost clinic hours.
Providers also emphasized the need for involving the media in promoting both colorectal cancer prevention information as well as new screening guidelines. The emphasis on media speaks to the reach it has on the general public as well as health care providers. Providers also encouraged utilizing patients who have had polyps removed and/or colorectal cancer survivors in media campaigns to promote screening. This would offer an opportunity to tell their personal stories, and also raise awareness among first-degree relatives who may be at higher risk of developing colorectal cancer. Respondents suggested using Katie Couric’s colonoscopy video and accompanying educational materials as a potential awareness strategy. Participants also recommended capitalizing on Kentucky “pride” in order to increase cancer screening. Essentially, if patients and providers were aware that Kentucky ranks higher than the national average for colorectal cancer incidence and mortality, they would be catalyzed to recommend and comply with screening.
The most trusted sources of information on colorectal cancer prevention and screening for the interviewed providers included:
Medical colleagues Professional organizations / societies Research and advocacy agencies
The most trusted source for all the types of colorectal cancer information— screening guidelines, state legislation, and media campaigns—was consistently medical colleagues. In addition to colleagues, the participants highlighted the importance of professional organizations and societies as trusted sources of colorectal cancer information. Locally, this includes the Kentucky Academy of Family Physicians, Kentucky Academy of Physician’s Assistants, Kentucky Coalition of Nurse Practitioners and Nurse Midwives, Kentucky Medical Association, and the Kentucky Nurses Association. The American College of Gastroenterology and the national bodies of their respective state professional societies were specifically mentioned as trusted national organizations. Research and advocacy agencies most commonly mentioned during the focus groups, as they relate to colorectal cancer screening information, were the American Cancer Society, Centers for Disease Control and Prevention, National Cancer Institute, and U.S. Preventive Services Task Force.
While not explicitly a discussion point of the focus groups, providers routinely mentioned needing reliable and accurate colorectal cancer information for their patients. For example, providers would like to have educational information readily available in their clinics to provide to patients when they recommend screening. This literature would highlight and reinforce the verbal information providers give to the patients regarding colorectal cancer prevention and early detection. Respondents requested posters for exam rooms as well as handouts for the patients, all including the message that colorectal cancer often has “no symptoms.” In addition, participants wanted to include content highlighting patients’ adherence to breast and cervical cancer screening, in the form of mammograms and Pap tests, as an example of the importance of colorectal cancer screening. Additional promotional ideas included: a traveling colon display, “Polyp Man” appearances from the American Cancer Society, interactive health kiosks, and electronic flashing freeway signs with health messages.
To our knowledge, this is the first project to explore Kentucky primary care physicians’, nurse practitioners’, and physician assistants’ preferences for receiving colorectal cancer prevention and screening information, particularly as it relates to screening guidelines, legislation and public awareness campaigns. A previous study focused on physician and office staff perceptions of barriers to colorectal cancer screening in Kentucky; however, this study utilized Appalachian-based practices and included only one question regarding preferred methods for receiving additional information on colorectal cancer screening.
It should be noted there are several limitations to the breadth and depth of these findings. Most notably, we are limited by the use of a convenience sample of providers recruited by three partner organizations who proactively volunteered to assist KCC with this project. We do not know which recruitment method (i.e., e-mail, mail, clinic mailboxes) was most successful in recruiting providers. It would be reasonable to assume that providers recruited by e-mail, also prefer e-mail as a means for receiving colorectal cancer information; therefore, the results may be biased by these participants. Additionally, the project budget was limited, allowing for only three to five total focus groups. As a result, it was not possible to ensure equal distribution of provider types, gender, and age within and among provider types, practice settings, racial diversity, and geographic residence. We cannot generalize our results to the larger primary care provider population in Kentucky, nor to the population of providers other comprehensive cancer coalitions may work with in their own communities.
While a perceived imbalance of power among provider types (physicians vs. non-physicians) could potentially play out in focus group discussions, this was not observed in the current project. Instead, we consider the inclusion of multiple primary care provider types a strength of the project. Research suggests nurse practitioners and physician assistants are motivated and willing to promote colorectal cancer screening among their patients.
As referenced earlier, KCC received colorectal cancer supplemental funding from CDC to conduct this project. The intent of this funding was to focus on improvements in public health practice rather than research-related activities. The funding guidelines influenced the investigative team’s decision to keep each focus group to less than ten participants to comply with the Office of Management and Budget (OMB) Paperwork Reduction Act
Despite these limitations, the inherent challenges to recruiting community-based providers,
KCC has had an active statewide Colon Cancer Prevention Committee since 2007. Utilizing results from this practice-based project, the committee is in the process of tailoring strategies and interventions to educate primary care providers with the latest colorectal cancer prevention and control information, as well as the most recent state and national colorectal cancer screening legislation. Funds from the Committee have already been utilized to disseminate Kentucky-specific colorectal cancer screening public awareness materials to local provider offices and clinics to increase ownership and support of the message. The KCC Colon Cancer Prevention Committee intends to utilize project findings in one or more of the following ways:
Research, synthesize, and collate colorectal cancer-related messages from trusted sources, and supply them to professional organizations for dissemination to their membership as these entities routinely update and maintain their members’ e-mail addresses.
Provide expert speakers for participation in regional and statewide professional meetings and conferences, providing continuing education credits. Plenary or breakout sessions could focus on recent colorectal cancer screening information and legislative opportunities.
Collaborate with primary care providers and their staff to facilitate dissemination of best practices to increase colorectal cancer screening. This may include the provision of timely education materials to patients and providers, as well as ready-made reminder/recall resources. The responsibility for tailoring and/or funding these resources would be the KCC Colon Cancer Prevention Committee, through both CDC funding and in-kind partner contributions, which is the foundation of comprehensive cancer control.
Identify and equip primary care providers and other specialists who are willing to speak with their colleagues about colorectal cancer, potentially traveling to geographically isolated communities in the state.
Garner resources to develop a coordinated colorectal cancer screening media campaign that will impact both the public and healthcare providers.
In closing, obtaining a direct assessment of primary care providers preferred methods, sources, and frequency of receiving colorectal cancer information informs strategies that can be implemented and evaluated in practice among comprehensive cancer control coalitions to impact colorectal cancer disparities. Considering that Kentuckians report their most significant barrier to receiving colorectal cancer screening is the lack of provider recommendation, the results of this project are most timely. Practical venues to reach healthcare providers with trusted and accurate colorectal cancer screening information is an essential component of the strategic comprehensive cancer control plan for our state.
This publication was supported by Cooperative Agreement Number 5U58DP000810 from the Centers for Disease Control and Prevention. The findings and conclusions in this article are those of the author(s) and do not necessarily represent the official position of the Centers for Disease Control and Prevention.
Scenarios, Questions and Prompts of Semi-Structured Interview Guide
| Scenarios | Questions | Prompts | |
|---|---|---|---|
| The American Cancer Society, Multi-Society Task Force on Colorectal Cancer, and the American College of Radiology as well as the American College of Gastroenterology recently published updated colorectal cancer screening and surveillance guidelines with a focus on colorectal cancer prevention. | Were you aware of these | N/A | |
| What are your | Textbooks, journal articles, conversations with colleagues, CME opportunities at conferences or online, academic detailers or educational facilitators, mailings such as newsletters, e-mail, text messages, websites | ||
| Kentucky Revised Statute 304.17A-257 requiring health benefit plans to provide coverage for colorectal cancer screenings, effective January 1, 2009, in accordance with ACS guidelines. Kentucky Revised Statute 214.540-544 establishing a colon cancer screening program within the Department of Public Health to provide screening services to uninsured individuals age 50 to 64 and others at high risk. | [Related to updated screening guidelines, colorectal cancer screening legislation, and public awareness campaigns], | American Cancer Society, National Cancer Institute, Kentucky Cancer Consortium, medical organizations or professional societies such as Kentucky Medical Association, pharmaceutical companies, the media, insurance companies, local health departments, government, hospitals, etc. | |
| The Kentucky Cancer Consortium plans to launch a colorectal cancer public awareness campaign aimed at increasing screening among Kentuckians wherein patients will be prompted by the awareness campaign to talk with their physicians about colorectal cancer screening. | Daily, weekly, monthly, quarterly, 2/year, once a year, as soon as there is new information | ||
Participant Characteristics by Focus Group
| Central | Western | Western | Eastern | Total | |
|---|---|---|---|---|---|
| Physician | 1 | 4 | 1 | 2 | 8 |
| Nurse Practitioner | 1 | 2 | 3 | -- | 6 |
| Physician Assistant | 2 | -- | 1 | -- | 3 |
| Men | 1 | 3 | 2 | 2 | 8 |
| Women | 3 | 3 | 3 | 3 | 9 |
| Average Age | 48 years | 52 years | 37 years | 43 years | 45 years |
| Non-Hispanic, White | 4 | 6 | 5 | 2 | 17 |
| Private Practice | 2 | 5 | 4 | -- | 11 |
| Other Practice Setting | 2 | 1 | 1 | 2 | 6 |
| Average Years of Medical Practice | 20 years | 22 years | 6 years | 11 years | 15 years |