Evaluation of an Intervention to Increase Colorectal Cancer Screenig in Primary Care Clinics - Clincians

Clinician Post-Intervention Survey

Clinical Care and Health Survey: Colorectal Cancer Screening

Clinician Opinion and Practice Questionnaire

MCO Research Arm Name and Battelle are inviting you to participate in this study of clinicians at MCO Name. The CDC is collaborating with Battelle and MCO Research Arm Name, to study ways to improve colorectal cancer screening in primary care.

We know that primary care clinicians use a variety of approaches to discuss colorectal cancer screening with patients over age 50. We are interested in your training, practice approaches, and opinions about screening for colorectal cancer. We are also interested in the institutional systems you use to facilitate routine screening.

Your answers are private. Collected survey data will only be reported in aggregate. We appreciate your taking the time to complete this survey. This questionnaire asks questions about your demographic and practice characteristics. It also includes sections that ask about your clinical practices and opinions regarding colorectal cancer screening. The survey was designed with input from practicing primary care clinicians like you.

Your participation in this study is voluntary. You may refuse to answer any or all questions on the survey. You are being paid $50 to compensate you for your time and effort. You will be contacted one more time in the future so that we may learn more about your training, practice approaches, and opinions about screening for colorectal cancer.

Clinicians who reviewed this questionnaire estimated that it took between 15 and 45 minutes to complete.

We appreciate your help in improving patient care at MCO Name.

Clinician Questionnaire

Part I: Clinician Characteristics

This first section asks a few questions about your personal background and your current practice.

1. What is your age? _________________

2. What is your sex?

 Male  Female

3. What is your primary specialty? ___________________________________ (Please specify)

4. What is your secondary specialty? ___________________________________ (Please specify)

 No secondary specialty

5. Since completing your training, how long have you been practicing? _______ Years

6. How long have you practiced at ____ (name of study clinic site) _________________?

____________ Years ____________ Months

Note: “Your clinic” = (fill with study clinic name)

Please complete remainder of survey with respect to your practice at (study clinic name)

7. On average, how many hours per week total do you spend in direct patient care in your clinic?

Average number of hours ______________

8. Approximately, how many patients are in your panel? ______________

9. On average, how many patients do you see in a typical week in your clinic? ______________

10. On average, approximately how many patients do you see in a typical week for health maintenance visits/exams in your clinic? ______________

11. On average, approximately what percent of the patients you see in your clinic are 50 years of age or older? __________ %

Part II: Preventive Services Opinions

1. How worthwhile do you consider each of the following preventive services for asymptomatic patients, age 50 and over, during health maintenance exams? (Check one box for each test)

Test and interval	Not at all worthwhile	Slightly worthwhile	Somewhat worthwhile	Quite worthwhile	Very worthwhile
a. Pap smear (every 3 years)					
b. Mammogram (annual)					
c. Digital rectal exam with hemoccult (annual)					
d. Fecal occult blood test (FOBT or hemoccult) (annual)					
e. Flexible sigmoidoscopy (every 5 years)					
f. Colonoscopy (every 10 years)					
g. Cholesterol test (annual)					
h. Prostate specific antigen (annual)					
i. Digital rectal exam to check prostate (annual)					

2. How often do you discuss the following issues with patients age 50 and over during a health maintenance exam? (Check one box for each test)

Issues Discussed	Never	Sometimes	Half the Time	Usually	Always
a. Smoking					
b. Alcohol use					
c. Exercise or physical activity					
d. Dietary practices					
e. Stress					
f. Depression					
g. Breast cancer screening					
h. Cervical cancer screening with Pap test (for women)					
i. Prostate cancer screening (for men)					
j. Colorectal cancer screening					
i. Fecal occult blood test					
ii. Flexible sigmoidoscopy					
iii. Colonoscopy					
iv. Barium enema					

3. How often do your patients (age 50 and over) bring up the following issues during a health maintenance exam? (Check one box for each issue)

Issues brought up	Never	Sometimes		Half the Time	Usually	Always
a. Cholesterol or heart disease risk and screening						
b. High blood pressure risk and screening						
c. Diabetes risk and screening						
d. Breast cancer risk and screening (for women)						
e. Cervical cancer risk and screening (for women)						
f. Prostate cancer screening (for men)						
g. Colorectal cancer screening						

The remainder of this survey is about colorectal cancer screening. We are interested in your opinions and practices about screening your patients age 50 and over who are asymptomatic and are presenting for a health maintenance exam.

Part III: Colorectal Cancer Screening: Your Training and Experience

The questions in this section ask about your personal training and experiences related to colorectal cancer screening.

1. In the past year, have you received specific training on any of the following topics?

	Yes	No
a. How to discuss colorectal cancer screening options with your patients		
b. Provision of fecal occult blood test (FOBT) (home test kit) to patients		
c. Recommending Flexible Sigmoidoscopy to patients		
d. Recommending Colonoscopy to patients		
e. Recommending Double contrast barium enema to patients		

2. In the past year, approximately how many new cases of adenomas or polyps have you detected or diagnosed among your asymptomatic patients, using each of the following screening tests?

Test	Number of Asymptomatic Cases
Fecal occult blood test (FOBT) (Hemoccult cards) (home test kit)
Flexible sigmoidoscopy
Colonoscopy
Double contrast barium enema
Other, specify _______________

3. In the past year, approximately how many new cases of colorectal cancer (including early stages) have you detected or diagnosed among your asymptomatic patients, using each of the following screening tests?

Test	Number of Asymptomatic Cases
Fecal occult blood test (FOBT) (Hemoccult cards) (home test kit)
Flexible sigmoidoscopy
Colonoscopy
Double contrast barium enema
Other, specify _______________

Part IV: Colorectal Cancer Screening Practices

Answer the questions in this section thinking about your patients age 50 years and over who are asymptomatic, and are presenting for a health maintenance exam.

1. For each statement below, please check how often you take each of the following actions when you see patients for health maintenance exams.

	Never	Sometimes	Half the time	Usually	Always
a. I discuss colorectal cancer when patients present with symptoms					
b. I discuss colorectal cancer (CRC) screening when patients present with questions or concerns					
c. I discuss CRC screening with patients who report risk factors in a medical history					
d. I have brochures available for all patients on CRC screening					
e. I discuss CRC screening with all age-appropriate patients and:
i. let them decide which screening method to use					
ii. recommend a specific test they should have					
iii. we come to a joint decision as to which screening method to use					
f. I discuss CRC screening when patients come in for acute care visits if there is time					
g. Other, (specify)._____________________					

In the questions that follow, we ask you about the recommendations you make to your patients. Even if your strategy is to encourage patients to share in decision-making, answer the questions in terms of what you would tell patients if they asked you directly what you recommend.

2. Which test or test combination do you most often recommend to your asymptomatic, average-risk patients age 50 and over, as a colorectal cancer screening strategy? (Check one box)

 I do not recommend routine colorectal cancer screening at this time

 Digital rectal exam alone

 Digital rectal exam and in-office hemoccult

 Fecal occult blood (hemoccult) test alone (patient home kit)

 Flexible sigmoidoscopy alone

 Colonoscopy alone

 Double contrast barium enema alone

 Either fecal occult blood test or flexible sigmoidoscopy

 Both fecal occult blood test and flexible sigmoidoscopy

 Both fecal occult blood test and colonoscopy

 Other (describe) _____________________________________________________

3. Please complete the table below based on your recommendations for colorectal cancer

screening to asymptomatic average-risk patients, aged 50 and over. If you do not recommend a particular test for screening purposes, check the appropriate box in the first column. To complete the recommended frequency column, please answer in terms of patients ages 50 and over who do not have any abnormal findings on previous tests.

	I do not recommend	Recommended starting age	Recommended frequency of testing	Is there an age at which you no longer recommend testing?	If yes, what age?
a. Digital rectal exam without hemoccult		______yrs →	Every _____yrs →	Yes →  No	______yrs
b. Digital rectal exam in conjunction with hemoccult		______yrs →	Every _____yrs →	Yes →  No	______yrs
c. Fecal occult blood test (FOBT) (Home kit)		______yrs →	Every _____yrs →	Yes →  No	______yrs
d. Flexible sigmoidoscopy		______yrs →	Every _____yrs →	Yes →  No	______yrs
e. Colonoscopy		______yrs →	Every _____yrs →	Yes →  No	______yrs
f. Double contrast barium enema		______yrs →	Every _____yrs →	Yes →  No	______yrs

4. For the last 10 patients aged 50 and older whom you saw for a health maintenance exam and were asymptomatic, please estimate how many of each of the following tests you performed or ordered for colorectal cancer screening?

Please write “0” if you did not order the test for any of these 10 patients.

Digital rectal exam with hemoccult _______

Fecal occult blood test (FOBT) _______

Flexible sigmoidoscopy _______

Double contrast barium enema _______

Colonoscopy _______

5. Among all patients aged 50 and older you saw for a health maintenance exam, in the past year, who were asymtoptomatic, for approximately what percentage did you perform or order each colorectal cancer screening test?

Digital rectal exam with hemoccult _______ %

Fecal occult blood test (FOBT) _______ %

Flexible sigmoidoscopy _______ %

Double contrast barium enema _______ %

Colonoscopy _______ %

Part V: Opinions about CRC Screening

For each statement below, please check the box that best represents your opinion.

1. Discussing colorectal cancer screening with my patients aged 50 and older would:	Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree	Strongly Agree
a. make me feel I am providing comprehensive care					
b. take too much of my time and effort					
c. be a higher priority with my male patients					
d. be low priority in my average health maintenance exam					
e. reassure patients					
f. give me an opportunity to provide reliable information and educate patients.					
g. be a topic that patients do not want to talk about					
h. cause my patients to feel uncomfortable or embarrassed					
i. be something that I feel prepared to discuss.					
j. distract from other patient needs.					

2. Distributing screening fecal occult blood tests (FOBT) to my patients aged 50 and older is:	Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree	Strongly Agree
a. a practice standard					
b. easy to do					
c. a low risk test for my patients					
d. difficult due to cultural or language barriers					
e. an opportunity for education about CRC screening					
f. a method to increase a patient’s role in their own health care					
g. cost effective					
h. difficult due to time constraints					
i. something I feel prepared to do					
j. other, (specify)_________________					

3. Having my asymptomatic patients aged 50 and older complete screening fecal occult blood test (FOBT) kits at home would:	Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree	Strongly Agree
a. be convenient for patients					
b. be a way to find CRC at an early stage					
c. be effective in decreasing mortality					
d. result in patients doing it wrong					
e. result in patients not returning cards					
f. be distasteful for patients					
g. worry my patients because of false positive results					
h. be difficult for patients					
i. produce inaccurate results					
j. other, (specify)_________________					

4. Having my asymptomatic patients aged 50 and older complete a screening flexible sigmoidoscopy would:	Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree	Strongly Agree
a. find most colorectal cancer at early stage					
b. be cost-effective					
c. reassure patients					
d. take too much of my time and effort to discuss and refer					
e. take too much time for patients					
f. miss a large part of the colon					
g. be effective in decreasing mortality					
h. be difficult/unpleasant for patients to prepare for					
i. be inconvenient for patients					
j. expose patients to significant risk of complications					
k. be something that patients would refuse to do					
l. be something that I feel prepared to discuss					
m. result in a long wait time for an appointment					
n. other, (specify)_________________					

5. Having my asymptomatic patients aged 50 and older complete a screening colonoscopy would:	Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree	Strongly Agree
a. be appropriate only for high risk patients					
b. be appropriate only as follow-up to other tests					
c. find colorectal cancer at an early stage					
d. reassure patients					
e. be preferred by most patients					
f. be the best test we can provide					
g. view the entire colon					
h. be effective in decreasing mortality					
i. take too much time for patients					
j. be difficult/unpleasant for patients to prepare for					
k. be inconvenient for patients					
l. expose patients to significant risk of complications					
m. be expensive for the patient					
n. be cost-effective					
o. take too much of my time and effort to discuss and refer					
p. be something that patients would refuse to do					
q. be something that I feel prepared to discuss					
r. result in a long wait time for an appointment					
s. other, (specify)_________________					

Part VI. Facilitators and Barriers to CRC Screening

We are interested in how various factors affect the ease or difficult of colorectal cancer (CRC) screening.

1. Do you use any of the following systems to remind you or your patients when they are due to be screened for colorectal cancer? (Check one box for each item)

	Yes	No
a. Flow charts, “tickler files,” or prompts to remind me or my staff if patients are due for a CRC screening via an FOBT		
b. Flow charts, “tickler files,” or prompts to remind me or my staff if patients are due for a CRC screening via a flexible sigmoidoscopy		
c. Flow charts, “tickler files,” or prompts to remind me or my staff if patients are due for a CRC screening via a colonoscopy		
d. Computerized printouts of my patients’ status on screening tests		
e. Reminder phone calls to patient		
f. Reminder cards by mail to patient		
g. Materials (e.g., handouts) or programs to educate patients		
h. Other (Please specify) _______________________		

2. On average, how long does it take for an asypmtomatic, average risk patient, aged 50 years or older, in your health care system to:

Get lab results to an Fecal occult blood test (FOBT) ____________________________

Get a Flexible sigmoidoscopy appointment ___________________________

Get a Colonoscopy appointment ____________________________

Get a Double contrast barium enema appointment ____________________________

3. How adequate do you find each of the following at your facility to support CRC screening? Using the scales below, please mark your opinion.

	Not available	Not at all adequate				Very adequate
a. A summary record of the patient’s screening tests (e.g., stable events summary)						
b. A computer-generated prompt or flag to remind you when a patient is due for a screening test						
c. A medical assistant generated prompt or flag to remind you when a patient is due for a screening test						
d. Tracking system to follow-up patients after referral to a flexible sigmoidoscopy appointment						
e. Tracking system to follow-up patients after referral to a colonoscopy appointment						
f. A patient reminder or recall system						
g. Materials (e.g., handouts) to educate patients about CRC screening						
h. Materials about CRC screening in languages other than English						
i. A convenient ordering, appointment, or referral system for flexible sigmoidoscopy						
j. A convenient ordering, appointment, or referral system for colonoscopy						
k. Staff trained to do patient education about FOBT (hemoccult) cards						
l. Staff to make patient appointments for flexible sigmoidoscopy and colonoscopy						
m. Reminder system for patient appointments for flexible sigmoidoscopy and colonoscopy						
n. Staff trained to do patient education about flexible sigmoidoscopy and colonoscopy preparation						
o. Facilities to perform colonoscopy in your health system						
p. Availability of FOBT kits (Hemoccult cards)						
q. Availability of timely flexible sigmoidoscopy appointments						
r. Availability of timely colonoscopy appointments						

Part VII. Support for CRC Screening

My discussing colorectal cancer screening options and methods with asymptomatic patients over 50 years of age who see me for a general health maintenance exam is something that:
	Strongly Encourage	Encourage	Neither Encourage nor Discourage	Discourage	Strongly Discourage
a. Patients generally					
b. My colleagues generally					
c. My primary professional medical organizations (specify) ________					
d. Governmental health organizations (e.g., CDC, NIH, State and Local Health Departments)					
e. Voluntary and non-profit health organizations (e.g., ACS)					
f. US Preventive Services Task Force, and other independent working groups					
g. Health insurance policies					
h. Medicare coverage policies					
i. The popular media (TV, radio, magazines)					
j. My group practice policies					
k. Clinicians in my clinic generally					

Part VIII. Satisfaction with CRC Training, Materials and Reminders

For each statement below, please check () the box that best represents your opinion.

1. Information, Training and Reminders:
	Strongly Disagree	Disagree	Neither	Agree	Strongly Agree
a. I have adequate information about colorectal cancer screening					
b. I have the latest information about colorectal cancer screening guidelines					
c. I have the skills I need to address colorectal cancer screening with my patients					
d. I feel prepared to answer patient questions about CRC screening					
e. Patients with flagged charts are more likely to receive an FOBT kit at their annual visit					
f. My clinic has seen an increased volume of consulting nurse phone calls about CRC screening					

2. CRC Screening Materials:
The materials that I currently use in my practice…	Strongly Disagree	Disagree	Neither	Agree	Strongly Agree
a. are helpful tools for my practice					
b. are easy for patients to understand					
c. have been well received by patients					
d. helped me gain new skills for addressing CRC screening in my practice					
e. helped me feel more able to answer patient questions about CRC screening					

The End

Thank you very much for completing your survey

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