Form #9 Form #9 Pre-intervention survey of clinicians and staff

Health Care Systems for Increasing and Tracking

Colorectal Cancer Screening Tests

Physicians & other clinicians — Complete Sections A to D.

All other staff — Complete Section C only

Name	____________________________________________
Role in the Practice	Physician Other clinician (CRNP, PA) Other clinical staff (specify) __________________ Other office staff (specify) __________________
Practice ID	_____________________
Date	|______|______|___ ___ | Month Day Year

CONFIDENTIALITY: If you do participate, all information collected in this survey will be kept strictly confidential. All information may be inspected by the Lehigh Valley Hospital and Health Network Institutional Review Board, and the researchers at the Lehigh Valley Hospital Department of Family Medicine. Only de-identified information will be provided to researchers at CNAC, researchers at Thomas Jefferson University and federal agencies to which we report this study's results. If any publications result from this research, results will be written in a way that will protect your identity. All information will be kept in a locked cabinet for ten years after the completion of the study and access will be limited to the above-mentioned groups.

A. Colorectal Cancer Screening Practices

(Physicians and Other Clinicians Only)

This section asks about different approaches to colorectal cancer screening. Please respond based on how you actually practice, even if this differs from how you would prefer to practice.

A-1. How frequently do you recommend the following tests for colorectal cancer screening to your asymptomatic, average-risk patients age 50 or older?

		Check one box on each line
	Tests	Very frequently	Somewhat Frequently	Not frequently	Never
A.	Colonoscopy	1 	2 	3 	4 
B.	Stool test alone Fecal occult blood test (FOBT)	1 	2 	3 	4 
	Fecal immunochemical test (FIT)	1 	2 	3 	4 
	Stool DNA test	1 	2 	3 	4 
C.	Other Flexible sigmoidoscopy	1 	2 	3 	4 
	Virtual colonoscopy (CT colonography)	1 	2 	3 	4 
	Double contrast barium	1 	2 	3 	4 
	Digital rectal exam	1 	2 	3 	4 

A-2 How effective do you believe the following tests are in reducing colorectal cancer mortality in asymptomatic, average-risk patients aged 50 years and older?

		Check one box on each line
	Tests	Very effective	Somewhat effective	Not effective	Don’t know
A.	Colonoscopy	1 	2 	3 	4 
B.	Stool test alone Fecal occult blood test (FOBT)	1 	2 	3 	4 
	Fecal immunochemical test (FIT)	1 	2 	3 	4 
	Stool DNA test	1 	2 	3 	4 
C.	Other Flexible sigmoidoscopy	1 	2 	3 	4 
	Virtual colonoscopy (CT colonography)	1 	2 	3 	4 
	Double contrast barium	1 	2 	3 	4 
	Digital rectal exam	1 	2 	3 	4 

B. Case Scenarios

(Physicians and Other Clinicians Only)

We would like your thoughts about the follow-up of these two hypothetical patients.

B-1. Your office is involved in a colorectal cancer screening program that involves sending stool tests to patients age 50 and older. Patients may complete and return stool test cards to a central lab for processing. Your office is informed of an abnormal screening test result for one of your patients.

What would you routinely do when you are informed that a patient has a positive stool test result?

Would you recommend . . .

Check all that apply

1  Repeat stool test?

2  Flexible sigmoidoscopy?

3  Colonoscopy?

4  Double contrast enema?

5  Other? (Specify) _______________________________________________________

______________________________________________________________________

B-2. Your office is involved in a colorectal cancer screening program that offers flexible sigmoidoscopy to patients age 50 and older. Patients may undergo a screening flexible sigmoidoscopy examination. Your office is informed of an abnormal test result for one of your patients.

What would you routinely do when you are informed that a patient has an abnormal flexible sigmoidoscopy result? Would you recommend . . .

Check all that apply

1  Stool test?

2  Repeat flexible sigmoidoscopy?

3  Colonoscopy?

4  Double contrast enema?

5  Other? (Specify) _______________________________________________________

______________________________________________________________________

C. Colorectal Cancer Screening Process in Your Office

(Physicians, Other Clinicians, and ALL Other Staff)

This section asks about how the colorectal cancer screening process occurs in your office. Please respond based on how this process actually works in your practice, even if this differs from how you would prefer things to work.

C-1. For screening stool tests, who in your practice actually performs the activity involved in each step below?

		Check all that apply.
		I do it	Another person does it (specify job title)	No one does it	Don’t know
a.	Gives stool test cards to the patient	1 	2  _______________	3 	4 
b.	Contacts non‑responders to stool test	1 	2  _______________	3 	4 
c.	Gives stool test results to patient	1 	2  _______________	3 	4 
d.	Refers patients with positive stool test for follow-up	1 	2  _______________	3 	4 
e.	Schedules follow-up for positive stool test patients	1 	2  _______________	3 	4 
f.	Contacts follow-up no-shows	1 	2  _______________	3 	4 
g.	Reschedules no-shows for follow-up	1 	2  _______________	3 	4 

C-2. For screening flexible sigmoidoscopy, who in your practice actually performs the activity involved in each step below?

		Check all that apply
		I do it	Another person does it (specify job title)	No one does it	Don’t know
a.	Orders screening flexible sigmoidoscopy	1 	2  _______________	3 	4 
b	Schedules flexible sigmoidoscopy	1 	2  ______ _________	3 	4 
c.	Contacts flexible sigmoidoscopy no-shows	1 	2  _______________	3 	4 
d.	Reschedules no-shows for flexible sigmoidoscopy	1 	2  _______________	3 	4 

C-3. For screening colonoscopy, who in your practice actually performs the activity involved in each step below?

		Check all that apply
		I do it	Another person does it (specify job title)	No one does it	Don’t know
a.	Orders screening colonoscopy	1 	2  _______________	3 	4 
b.	Schedules colonoscopy	1 	2  _______________	3 	4 
c.	Contacts colonoscopy no-shows	1 	2  _______________	3 	4 
d.	Reschedules no-shows for colonoscopy	1 	2  _______________	3 	4 

D. Background of Your Patients and Yourself

(Physicians and Other Clinicians Only)

D-1a During the past 12 months, how many (number) newly-diagnosed colorectal cancer patients have you personally seen in your practice? An estimate is fine.

|_________| newly-diagnosed colorectal cancer patients

D-1b During the past 12 months, how many (number) newly-diagnosed colorectal adenomatous polyp patients have you personally seen in your practice? An estimate is fine.

|_________| newly-diagnosed colorectal adenomatous polyp patients

D-2a During the past 12 months, approximately what percentage (%) of your newly-diagnosed colorectal cancer patients was diagnosed because they had a symptom (e.g. hematochezia, weight loss, abdominal pain or bloating)? An estimate is fine.

|_______% | of newly-diagnosed colorectal cancer patients

D-2b During the past 12 months, approximately what percentage (%) of your newly-diagnosed colorectal adenomatous polyp patients was diagnosed because they had a symptom? An estimate is fine.

|_______% | of newly-diagnosed colorectal adenomatous polyp patients

D-3a During the past 12 months, approximately what percentage (%) of your newly-diagnosed colorectal cancer patients was diagnosed because they had an FOBT-positive result? An estimate is fine.

|_______% | of newly-diagnosed colorectal cancer patients

D-3b During the past 12 months, approximately what percentage (%) of your newly-diagnosed adenomatous polyp patients was diagnosed because they had an FOBT-positive result? An estimate is fine.

|_______% | of newly-diagnosed colorectal adenomatous polyp patients

D-4. On average, how many patients do you see each week?

1  Less than 100

2  100-124

3  125-149

4  150 or more

D-5. What is your date of birth? |______|______|___ ___ |

Month Day Year

D-6. What is your gender? 1  Male 2  Female

D-7. Do you consider yourself to be Hispanic or Latino?

1  Yes 2  No

D-8. Do you consider yourself to be . . .

1  American Indian or Alaska Native

2  Asian

3  Black or African American

4  Native Hawaiian or Pacific Islander

5  White

6  More than one race

7  Other (Please specify) _______________________________________

D-9. Do you as an individual have an affiliation with a medical school or nursing school, such as adjunct, clinical, or other faculty appointment?

Check one box

1  Yes (Specify what medical or nursing school) ______________________________

2  No

D-10. Physicians only -- What is your primary medical specialty?

Check one box

1  Family medicine

2  General practice

3  General internal medicine

4  Obstetrics/Gynecology

5  Other (Specify) __________________________________________________

D-11. Physicians only -- Are you board-certified in that specialty?

Check one box

1  Yes 2  No

D-12a. Physicians only --- In what year did you graduate from medical school? |___|___|___|___|

Year

D-12b. Other clinicians only -- In what year did you receive your highest clinical degree? |___|___|___|___|

Year

Thank you for sharing your opinions with us.

Surveys will be collected at the end of academic detailing session. Or surveys can be returned in envelope given to the office manager.

If you have any questions about the survey, please contact:

Melanie Johnson, EPICnet Coordinator

LVHHN, Department of Family Medicine

17^th and Chew Streets, SON, P.O. Box 7017

Allentown, PA 18105-7017

610-969-4922

[email protected]

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