“The 50 – Year Project: Examining Colorectal Cancer Screening History Among Peninsula Institute for Community Health Patients Aged 50 Years and Older ” Jewel S. Goodman, MPA, PhD(c) 1 ; Stacey B. Plichta, ScD 1 ; Angela Futrell, RN 2 ; and Syed Kalamuddin, DDS, MPH 2 1 College of Health Sciences, Old Dominion University, Norfolk, Virginia and 2 Peninsula Institute for Community Health, Newport News, Virginia About PICH Background and Purpose In the US, Colorectal Cancer (CRC) is reportedly the second leading cause of cancer-related deaths. A person’s lifetime risk of developing CRC is approximately 6%, with nearly all (90%) CRC cases occurring after age 50. CRC is preventable with timely and accurate colon screening and subsequent removal of polyps that result in development of cancer. Medical research suggests it may take 10 years for this to occur, but the colonoscopy screening examination allows recognition of polyps years before they become dangerous. Screening begins at age 50 years and over and can reduce mortality rates of colon cancer. Over the past 20 years, CRC rates among whites has decreased, but remained constant among African Americans. Of all racial / ethnic groups in the US, African Americans have the highest mortality rates among CRC fatalities. Both men and women are at equal risk. The overall goals of the project were to: actively engage existing patients in discussing their experience with receiving referrals from their PICH physicians to have the colonoscopy screening performed, particularly if they are age-appropriate; and to demonstrate any methods by which PICH could ultimately improve its available pool of resources to assist patients in meeting the recommendations of their physicians as it relates to having the colonoscopy performed. Surveys were administered and focus groups, medical staff interviews, and a medical records review were conducted. The Peninsula Institute for Community Health (PICH), a private, non-profit community health center established in 1978, served an estimated 24,440 unduplicated insured and uninsured patients in Uninsured patients pay based upon family size and income. PICH has three primary care practices, a community dental project, a Health Care for the Homeless program, two school-based health centers, and a pharmacy program to increase access to prescription medications for low-income and uninsured patients receiving care from area safety-net providers. Medical Staff Interview Results A standard protocol for referrals must be implemented so that all age-appropriate patients are referred at the primary care physician level. This project illustrated that although patients are not afraid of the fecal occult blood test, they need more education about the Colonoscopy and what the screening can detect, the impact on their overall health, and increased awareness of free cancer screening events. A collaboration with screening specialists is recommended. Discussion Screening History: When asked if they had a Fecal Occult Blood Test (FOBT) performed, most (n=8, 80%) reported no and when asked if they had been referred for the colonoscopy screening, more than half (n=6, 60%) had not. Those referred for a colonoscopy presented with symptoms such as incontinence, blood in stool, and bowel movement inability, not age. Establishing and Increasing Level of Knowledge: When asked if they knew what a colonoscopy screening examination entailed, participants revealed they were familiar with the term and its link to cancers. A patient stated, “the closest I can come would be cancer of the rectum or the organs that involved in elimination.” One participant stated, “it is something to do with the intestine, the colon, the rectum and the anus”. Among those patients who were referred, they reported the physicians and medical staff failed to provide any explanation of why the procedure was necessary, what the results would show, nor what would happen to them during the screening. Patients agreed that informational handouts would be beneficial to age-appropriate patients not experiencing any symptoms. Determining the Levels of Responsibilities and Follow-up: Participants discussed having nursing staff create a document to accompany medical records of all patients aged 50 years and older to assist physicians in appropriate referrals, “maybe the nurse could do something...tell the doctor, hey look, this here man is 52 and he ain’t got no blood in the stool or nothing, but we still need to send him out for the thing [colonoscopy screening] just cause of his age.” Among those patients who were referred, but had not complied because they did not have insurance, discussion entailed PICH providing resources to assist patients. “See, I have Medicaid and Medicare, so mines will probably be covered, but somebody ain’t got no insurance, what about them, what do you tell them.” Participants suggested PICH provide the colonoscopy screening at a reduced rate as it does with other extended services so that patients can afford it; provide the contact information for facilities that have cheaper rates for the screening; contact information for medical centers that provide the screening free-of-charge; and lastly, provide the additional facets necessary such as transportation assistance. Focus Group Results, cont. Of the 55 medical records reviewed, majority were male (n=32, 58%); 38 had not been referred by their PICH physician for a Colonoscopy nor a FOBT. Of the remaining 17 medical records, two had been referred for the FOBT but no test results in file; 10 had been referred for the Colonoscopy, but no results in file; five had been referred for the Colonoscopy and had participated in the screening; four within the past year; majority female (n=4) and ranged in ages from years. Medical Records Review Results Survey Administration Results Forty-eight (48) participants completed the survey administered at the 16th Annual Screening Event. Most were female (n=29, 60%); African American (n=39, 81%); and between the ages of 50 – 59 years (n=20, 42%) with a mean age of 56 years. The event was open to the public, approximately half (n=27, 56%) were PICH patients. Of the 15 patients aged 60 years and older, nearly all (n=14, 93%) had a FOBT. The majority (n=13, 87%) had been referred for and completed the Colonoscopy screening, with more than half (n=8, 62%) within the past 12 months. One participant was referred but failed to follow-up due to transportation. Of the 20 patients aged 50 – 59 years, almost half (n=9, 45%) had a FOBT; two-thirds (n=14, 70%) had not been referred for the Colonoscopy screening; 30% (n=6) had been referred for the Colonoscopy and nearly all (n=5, 83%) had the screening completed. One participant did not follow-up reported transportation problems. Four of the five patients who had the screening performed had either Medicare or Medicaid health insurance coverage and one had no insurance. Focus Group Results Demographics: Participants (n=10) were evenly distributed as male and female, majority African American (n=9, 90%), and between the ages of years (n=6, 60%) with a mean age of 53.7 years. More than half (n=6, 60%) reported a household annual income of $20,000 or less; 40% (n=4) reported Medicaid or Medicare as current health insurance, and another 30% (n=3) reported not having health insurance. One MD, one PA, two Referral Specialists, three LPNs, and one RN responded. When asked to describe the selection criteria used to select patients to refer for the FOBT or the Colonoscopy screening, participants responded: abdominal pain, frequent urination, rectal exam results, constipation, Irritable Bowel Syndrome, rectal bleeding, change in stool, acid reflux, family history, age, and medical history. When asked to list all factors that patients have shared with them concerning non-compliance with referrals for the screening, medical staff reported: bad prior experience in the health system, men feel violated by the procedure, patient thinks the procedure is painful, no insurance, history of non-compliance, uncomfortable with an instrument in the rectum, no symptoms, no current problems, and afraid of the possible results.