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2017 NAPCRG Annual Meeting

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PR2 CASFM 2017 Course on Methods to Advance Primary Care Research

Gillian Bartlett, PhD; Chester Fox, MD; Lee Green, MD, MPH; Joseph LeMaster, MD, MPH; Christopher Morley, PhD; Maeve O'Beirne, MD, PhD; Andrew Pinto, MD, MSc, CCFP, FRCPC; Charo Rodriguez, MD, MSc, PhD; Jon Salsberg, PhD; Allen Shaughnessy, PharmD, MMedEd; Hazel Tapp, PhD; Tyler Williamson, PhD; Richard Young, MD

11/17/17 9:00 AM - 5:00 PM Rue Mansfield

Building on the success previous years, this course is organized by the Committee on Advancing the Science of Family Medicine (CASFM) to provide information on emerging research methodologies and/or applying existing methods in novel contexts, so that new researchers or those changing their research focus may further expand their research skills. The course provides a unique educational opportunity to those interested in developing a foundation, expanding, or refreshing their research skills. Objective: To provide instruction in various aspects of basic and advanced research methods relevant for primary care. Content: General concepts in qualitative and quantitative research will be made available through online webinars offered in advance of the course. The full day course will be offered with a general introduction to the work of CASFM in the morning session, an icebreaker activity and an introduction to the working groups followed by a 90-minute concurrent session in the morning and a 3-hour afternoon concurrent session focusing on different aspects of research methodology. Participants will be able to chose from concurrent sessions organized by five of the six CASFM Work Groups including Research Methods (RM), Health Information Technology (HIT), Practice-Based Research Network (PBRN), Participatory Research in Primary Care (PRPC), and Cost Analysis (CA). Method: The morning will include a 45-minute lecture style introduction session while the concurrent sessions will be organized as interactive courses. Three concurrent 90 minutes sessions will run in the morning. In the afternoon, four 3-hour concurrent sessions will be offered. Participants will not only be provided with substantive material but will also be actively participating in the course through engagement exercises and in-class activities. This method has been shown to promote retention of the material and minimize the time burden for the participants. The day is organized so that participants can pick and choose two of the seven sessions they would like to attend. During the lunch, all course instructors will be available to mix with attendees and answer questions in an "Ask the Experts" panel. Prerequisite Knowledge: Two introductory webinars on quantitative and qualitative methods will be made available to participants to better prepare them for the day. A set of three webinars will also prepare attendees who wish to participate in the Cost Analysis session.

PR3 Place Matters: Mapping Tools and Data Resources for Doing Population Health (Introductory Topic in GIS)

Mark Carrozza; Michael Topmiller, PhD; Andrew Bazemore, MD, MPH; Keith Gardner; Jené Grandmont; David Grolling; Jennifer Rankin, PhD

11/17/17 9:00 AM - 12:00 PM Rue McGill

Objectives: This INTRODUCTORY GIS preconference session will enhance participants' understanding about the importance of geography to population health, give a practical understanding of the tools, methods, and data available to do population health research and practice, and consider ways in which care providers can use these resources to inform their practice. Content: Place matters to personal and population health. Understanding the community context of patients has become increasingly important in the primary care research domain. In light of the growing interest in this area of research, multiple tools have been developed to help physicians use these concepts at both the research and practice level. This hands-on workshop will introduce participants to a variety of geographic information analysis and data dissemination tools, as well as discuss ways in which community-level data can help inform research and care. Participants will review the existing primary care research highlighting population health and the importance of Social Determinants of Health, access hundreds of community-level data points, and consider how they can begin to use the combination of data and geography to positively affect health outcomes by making changes both at the community level and at the point of care. The workshop will include real-world examples of spatial primary care research and application. Method: Didactics, discussion, and hands-on computer workshop using GIS software and web-based mapping applications. We will provide sample data to use in applying concepts taught in the session and incorporate examples from a variety of primary care domains. Participants are encouraged to bring their own examples. Prerequisite Knowledge: None

PR4 Doing Population Health: A Hands-On, Geospatial Approach for Creating Service Area Maps and Identifying Priority Areas of Need

Mark Carrozza; Andrew Bazemore, MD, MPH; Keith Gardner; Jené Grandmont; David Grolling; Jennifer Rankin, PhD; Michael Topmiller, PhD

11/17/17 1:00 PM - 4:00 PM Rue McGill

Objectives: This intermediate preconference session will build on the introductory GIS session and enhance participants' understanding on how to do applied population health research, provide strategies and tools for defining their "population," and allow participants to create their own service area and penetration maps to identify high-need and priority areas. Content: It is well established that understanding and addressing the social determinants of health are critical for improving population health, and that primary care physicians play a key role. An emerging number of strategies and tools exist that can help population health researchers explore the distribution of health outcomes and determinants over various geographies. This hands-on workshop will provide participants with strategies for making clinical data actionable to improve population health; topics include - defining the "population," extracting and aggregating clinical data, mapping service areas and penetration rates, identifying priority geographies, and integrating social determinants of health. Method: Didactics, discussion, and hands-on computer workshop using Microsoft Excel, GIS software, and web-based mapping applications. We will provide sample data to use in applying concepts taught in the session and incorporate examples from a variety of primary care domains. Participants are encouraged to bring their own examples. Prerequisite Knowledge: None, though INTRODUCTORY GIS WORKSHOP RECOMMENDED

P101 Examining Perspectives on Interprofessional Patient Care and Collaboration: Including Psychology at a Multisite Academic Family Health Team

Jennifer Rouse, PhD; Kelly McShane

11/18/17 9:20 AM - 10:20 AM Sq Dorchester & Parc Mount Royal ABC

Context: In Canada, various governments have recently announced increased funding for mental health care, including access to psychotherapy. One way identified to expand access to mental health treatment is through the inclusion of Psychology in primary care models such as family health teams (FHTs). However, few psychologists have been recruited into primary care. Moreover, research examining the benefits and challenges of adding Psychology has been limited. Given the potential for expansion in this area, it is necessary to evaluate the impact of including Psychology in a FHT setting with regards to interprofessional patient care and collaboration. Objective: To examine perspectives on interprofessional patient care and collaboration from various stakeholders at a multisite academic FHT. Design: One-on-one interviews; thematic analysis of data using a pragmatic lens. Setting: A graduate-level psychology training clinic integrated into a downtown Toronto academic FHT. Participants: Seventeen participants, including nine past or present student trainees, four health care providers (e.g. physicians; social work; nursing), and three clinical psychology supervisors. Main and Secondary Outcome Measures: To gather experiential knowledge, participants were asked questions based on six key contextual factors derived from the literature: knowledge, environmental context and resources, team vision/scope of practice, communication, satisfaction, and competency/confidence. Results: Nineteen themes were derived from the data that fell into four overarching categories: divergent perspectives resulting from an emerging interprofessional model; physical features and collocation; addition of Psychology to the academic FHT; and perspectives on interprofessionalism and teamwork. Conclusions: Participants reported that including Psychology into the academic FHT was positive overall and filled a service gap. Beliefs congruous to the interprofessional FHT model were identified; however, barriers to fully embracing a team approach were identified. Results from this study may be helpful for FHTs considering the inclusion of Psychology as Canada moves towards expanding mental health care delivery.

P102 Evaluation of a Brief Mindfulness Based Stress Reduction Group Pilot Offered in a Primary Care Setting

Vela Tadic, MSW RSW; Eizabeth Muggah, MD, MPH, CCFP

11/18/17 9:20 AM - 10:20 AM Sq Dorchester & Parc Mount Royal ABC

Context: 8-week group-based Mindfulness Based Stress Reduction (MBSR) has been shown to help with stress and mood. There is emerging research on the benefits of a four-week MBSR. Objective: Evaluate the effectiveness of a four-week MBSR Group in a primary care setting. Design: Cohort study. Setting: An urban, academic, interdisciplinary primary care practice in Ottawa, Canada with an approximate patient population of 16,000. Patients or Other Participants: Adult patients voluntarily self-selected, or by recommendation of their health or mental health care provider. Those with severe mental health conditions, active suicidal ideation or active substance use, previous participation in another formal mindfulness program were excluded. Eligibility was determined by an individual intake session with a social work facilitator. Intervention: A four-week 1.5 hour MBSR co-facilitated by two social workers with beginner MBSR facilitator training. Main and Secondary Outcome Measures: Primary outcome: practice of mindfulness using the validated Five Facet Mindfulness Questionnaire. Secondary outcomes: participant satisfaction. Results: Complete data analysis pending. Two groups completed the program for a total of 12 participants over a 24 month period. Participants in the first group reported increases in mindfulness in all five facets that were generally maintained at 1, 3 and 6 months. Participant satisfaction was high. Conclusions: We successfully delivered a brief MBSR program led by social workers within a primary care setting with sustained improvements in mindfulness albeit with a small sample size. Process outcomes were not evaluated to identify which specific formal and/or informal mindfulness practices and/or teachings may have contributed to improvement in mindfulness practice, and whether or not level of teacher training would have differential impact.. Going forward, two additional programs will be offered to further explore the effectiveness and sustainability of the program.

P103 The 2 Year Course of Medically Unexplained Physical Symptoms (MUPS): Results of the PROSPECTS Study

Nikki Claassen-van Dessel, MD; Johannes van der Wouden, PhD; Trynke Hoekstra; Joost Dekker; Henriette van der Horst, MD, PhD

11/18/17 9:20 AM - 10:20 AM Sq Dorchester & Parc Mount Royal ABC

Context: Medically Unexplained Physical Symptoms (MUPS) are symptoms which last for at least several weeks and for which no sufficient explanation can be found after medical examination. High quality evidence about the long term course of MUPS and factors associated with this course is scarce. Objective: To assess the course of MUPS, to identify different course types and to develop a prediction model for the course of MUPS. Design: Prospective multicenter cohort study Setting: We recruited MUPS patients in general practices and in specialized care programs for MUPS. Patients: Eligibility was based on medical judgment and a minimal score of 2 on one or more symptoms of the Patient Health Questionnaire-15 (PHQ-15) Main and secondary outcome measures: We will use data collected at baseline and at 6, 12 and 24 months of follow-up. Primary outcome measures are symptom severity and degree of functional impairment. Potential predictors are based on current theoretical models describing the perpetuation of MUPS and include somatic, psychological and social factors. Latent Class Growth Mixture Modelling will be used to identify distinct course types. Logistic regression analysis will be used to identify risk factors associated with these course types and to develop one or more prediction models. Results: 325 patients completed the baseline assessment. 75% were women (N = 244). Mean age was 46.5 years (SD 12.3, range 19-70). 110 patients (33%) had mild MUPS (scoring 0-9 on the PHQ-15), 104 patients (32%) had moderate MUPS (score 10-14) and 111 patients (34%) had severe MUPS (score 15-30). 2-years data collection will be completed in April 2017. We expect a loss to follow-up of 15%. Conclusions: Patient recruitment and data collection progressed well. The diversity in PHQ-15 scores indicates that a broad range of MUPS patients has been selected. Further results will be presented at NAPCRG 2017.

P104 How Can Family Physicians Improve Their MUS Consultations According to Patients?

Juul Houwen; Peter Lucassen, MD, PhD; Hugo Stappers; Pim Assendelft, MD; Sandra van Dulmen; Tim olde Hartman, MD, PhD

11/18/17 9:20 AM - 10:20 AM Sq Dorchester & Parc Mount Royal ABC

Context: medically unexplained symptoms (MUS) are symptoms for which no biomedical cause can be found. General practitioners (GPs) experience difficulties in managing these consultations and patients with MUS are often not satisfied with the care they receive. Objective: to explore problems MUS patients experience in communication during consultations with the aim to improve MUS consultations. Design: qualitative study of patients' comments about their own video-recorded consultation; the comments were recorded on audiotape, transcribed and analyzed according to the principles of thematic analysis with constant comparison of the data. Setting: consultations with family physician in primary care Patients: patients with MUS reflecting on the video registration of their own consultation.. Outcomes: judgments of MUS patients about the quality of the communication of their family physician during the consultation Results: we recorded 393 consultations on video of which 43 concerned MUS. Twenty-two patients did identify problems during the MUS consultation. Patients identified six categories of problems. First, they report a mismatch between the GP's and their own agenda. Second, patients indicate that the GP evokes an unpleasant feeling during the consultation. Third, they experience that GPs do not provide a specific management plan for their symptoms. Fourth, patients indicate that the GP is not well prepared for the consultation. Fifth, they perceive prejudgments of the GP during the consultation. Finally, patients experience that the GP does not acknowledge a limited understanding of the origin of the symptoms. Conclusion According to patients, GPs can improve their MUS consultation by making genuine contact, by paying more attention to the patient's agenda and by avoiding evoking unpleasant feelings and displaying prejudgments. They should prepare their consultations and focus on the issues that matter for patients, for example symptom management. GPs should be unambiguous to patients when they do not understand the origin of symptoms.

P105 Determining Medication-Assisted Treatment (MAT) Capacity in High-Need Areas

Michael Topmiller, PhD; Aaron Vissman; Mark Carrozza; Jené Grandmont; Jennifer Rankin, PhD

11/18/17 9:20 AM - 10:20 AM Sq Dorchester & Parc Mount Royal ABC

Context: The US is facing an epidemic of opioid overdose deaths, led by states such as Ohio, Kentucky, and West Virginia. Important prevention strategies involve restrictions on opioid prescribing practices and increases in the capacity to provide medication-assisted treatment (MAT) in disproportionately affected areas. Primary care physicians are poised to play a key role in improving access to treatment. Few studies have examined geospatial distribution of MAT capacity across high-need areas. Objective: To determine MAT capacity in high-need areas. Design: Geospatial analysis of secondary data. Outlier analysis and mapping (including percentile and standard deviation maps) are used to identify outliers (higher than normal rates), while the Local Moran’s I tool is used to identify clusters of regions with higher than normal rates. Opioid Treatment Programs (OTPs) and DATA-waived physicians are mapped by rates per population. Setting: US National Drug Use Survey Regions. Outcome Measures: Illicit drug dependence and abuse rates and drug poisoning mortality by National Drug Use Survey (NDUS) Region. Treatment capacity is defined as the number of opioid treatment programs per population and the number of DATA-waived physicians (physicians able to provide MAT) per population. Preliminary Results: While many high-need regions have higher rates of MAT capacity, many of the highest-need regions lack OTPs and DATA-waived physicians, particularly primary care physicians. Conclusions: Increasing access to MAT is critical for dealing with the opioid and drug overdose epidemic. Targeting high-need areas is an important first step.

P106 UPSTREAM! Together to Prevent Mental, Emotional and Behavioral Problems

Larry Green, MD; Douglas Fernald, MA; Emma Gilchrist, MPH

11/18/17 9:20 AM - 10:20 AM Sq Dorchester & Parc Mount Royal ABC

Context: Mental, emotional, or behavioral (MEB) problems have been consistently identified as a top priority in communities across Colorado. There are evidence-based programs that prevent MEB problems, but they are not widely implemented. This represents a large, missed opportunity to improve population health. Objective: UPSTREAM! Together is a Colorado, USA-based project aiming to establish three communities of solution, the people who must work together to solve an important problem, poised to implement in 2018 locally defined and community-designed projects to prevent MEB problems. This poster will report the target problems and interventions selected by communities, participating partners, and early lessons concerning the development of prevention programs. Design: Community, philanthropic, and university collaboration using Boot Camp Translation, a community engagement process by which medical information is translated into concepts, messages, materials, and interventions that are meaningful to community members, actionable to improve local health, and evaluable. Settings: San Luis Valley, North East Colorado, and 2040 Partners for Health neighborhoods surrounding University of Colorado health science center campus. Participants: 12-16 community leaders from each of the three communities and facilitators. Results: This poster will present for each community the selected priority MEB problem, the selected adaptive approach to preventing the problem, and key lessons learned by the collaborators. Conclusion: This work in progress is expected to be poised for implementation and compete for funding in 2018. Next Steps: Align an adaptive evaluation based on RE-AIM framework capable of understanding what happens with each community’s prevention programs and its effects on key outcomes that matter to the communities. Seek implementation funding.

P107 Initiation of Pharmacological Treatment for Depressive Symptoms in Primary Care: A Six-Month Observational Study of Treatment Response and Self-Reported Symptomatology

Pasquale Roberge, PhD; Annie Benoit; Maxime Bergeron; Christine Boudrias; Geneviève Brassard; Sabrina Paquin; Antoine Seguin; Melissa Thibault; Mireille Luc; Marie Hayes; Joanie Rinfret; Vincent Morissette-Thomas

11/18/17 9:20 AM - 10:20 AM Sq Dorchester & Parc Mount Royal ABC

Context: Major depression presents a high risk of recurrence and chronicity and approximately half of patients receive a minimally adequate treatment according to clinical practice guidelines. Few patients achieve remission with first-line treatment with a single antidepressant, and symptom monitoring may provide important information to modulate pharmacotherapy. Objectives: To evaluate treatment response and remission rates over six months in patients initiating a SSRI or SNRI treatment for depressive symptoms, and to document family doctors' prescribing practices. Design: Prospective observational study. Setting: Two university-affiliated primary care clinics. Patients: Twenty-four adults initiating a SSRI or SNRI treatment. Main outcome: Web-based monthly self-reported Patient Health Questionnaire (PHQ-9) for depression symptom severity monitoring and clinical data from electronic medical records. Results: Analyses indicate a reduction in PHQ-9 scores from 14,7 +- 5,4 at baseline to 6,2 +- 4,3 at six months. The greatest improvement was observed within the first four months. Furthermore, after six months, 88% showed an improvement (reduction of at least 20%) and 59% met remission criteria (PHQ-9 <5). The main molecules prescribed were citalopram and sertraline, and psychoeducation frequently accompanied initial prescription. The most frequent strategies for limited treatment response were dose increase and addition of a second medication. Conclusions: While symptoms of many patients improve, these findings underline the importance of symptom monitoring to optimise depression treatment and remission.

P108 Mindfulness-Based Relapse Prevention for Alcohol Dependence: Findings From a Randomized Controlled Trial

Aleksandra Zgierska, MD, PhD; Cindy Burzinski, MSc; Marlon Mundt, PhD

11/18/17 9:20 AM - 10:20 AM Sq Dorchester & Parc Mount Royal ABC

CONTEXT: Alcohol dependence is among the top preventable causes of death in the U.S. Existing treatments are sub-optimal. Relapse is common and associated with negative socio-economic and health consequences, frequently managed by primary care clinicians. OBJECTIVE: To assess efficacy of a novel mindfulness-based intervention for relapse prevention in alcohol dependence. DESIGN: 26-week randomized controlled trial comparing Mindfulness-based Relapse Prevention for Alcohol Dependence (MBRP-A) adjunctive to usual care (MBRP-A group), to usual care alone (wait-list control group). Participant follow-up was completed; statistical analyses are ongoing (ClinicalTrials.gov NCT01056484). SETTING: Outpatient addiction treatment programs. PARTICIPANTS: 123 alcohol dependent adults (41.2+-11.9 years old; 56.9% male; 91% Caucasian) in early recovery (2 to 14 weeks after quit date). INTERVENTION: MBRP-A consisted of eight weekly therapist-led group sessions (total: 16 hours) and daily home practice. OUTCOME MEASURES: Daily alcohol consumption and drinking-related consequences assessed at baseline, 8 and 26 weeks with the Timeline Followback method and Drinker Inventory of Consequences questionnaire respectively. RESULTS: Randomization was effective. Preliminary analyses showed participants (64 MBRP-A, 59 control) reported drinking on 59.4+-34.8% and heavy-drinking (5 drinks/day for men, 4 drinks/day for women) on 50.4+-35.5% of days prior to their quit date, and scored 49.1+-21.9 for drinking-related consequences at baseline. At 26 weeks, 105 participants provided outcome data, reporting drinking on 8.7+-18.0% and heavy-drinking on 3.8+-9.0% of days, and scoring 14.0+-17.4 for drinking-related consequences, without statistically significant differences between the groups over the 26-week follow-up (p>0.05, intention-to-treat repeated measures analysis). CONCLUSIONS: In this study of alcohol dependent adults in early recovery, treatment with both MBRP-A, adjunctive to usual care, and usual care alone, resulted in rare relapse that was not different between groups over 26 weeks.

P109 Update on Treatment Options for Prostate Cancer Study (TOPCS): A PopulationBbased Survey of Men With Low-Risk Localized Prostate Cancer

Jinping Xu, MD; Michael Goodman; Cathryn Bock, PhD; Jacquelyn Keen; Loree Mincey; James Janisse; Elaine Brockman; Kendra Schwartz, MD, MSPH

11/18/17 9:20 AM - 10:20 AM Sq Dorchester & Parc Mount Royal ABC

Context: Active Surveillance (AS) is a reasonable treatment option for low-risk localized prostate cancer (LPC). Limited data are available as to AS adoption, which hinders physicians in counseling men about treatment options. Objective: To determine prevalence and racial differences in AS adoption among men with low-risk LPC. Design: Longitudinal cohort study. Setting: Population-based sample recruited from two cancer registries. Patients: Black and white men <=75 years with newly diagnosed low-risk LPC. Instrument: Mailed survey. Main and Secondary Outcome Measures: Treatment choice and quality of life. Results: Of the 1394 patients enrolled to date, 785 (56.3%) were recruited from metropolitan Detroit and 609 (43.7%) were from Georgia. Overall, 77.6% were white and 21.2% were black, with a mean age 62.7 years (SD=6.9, range 39-76). About 82% of patients had >=high school education, 53.9% had income >=$70,000/year, 53.5% were employed, 80.6% were married, and almost all (99.4%) had insurance. Compared to white men, black men were younger (61.0 vs. 63.1 mean years, p<0.001), had lower education (66.4% vs. 85.8% had >=high school education, p<0.001) and income (37.6% vs. 75.2% had >=$50,000/year, p<0.001), and less likely to be married (61.2% vs. 86.2%, p<0.001). Treatment data indicated that about half of the men (52.5%) chose observation (44.8% AS, 7.7% watchful waiting), 26.9% surgery, 18.1% radiation, 1.2% cryotherapy, and 1.3% other treatment. Treatment choice was associated with location (Detroit vs. Georgia) and race. Black men chose observation less often than white men (44.7% vs. 54.8%, p<0.01), and radiation more often (25.5% vs. 16.3%, p=0.001). Compared to men in Detroit, men in Georgia chose observation less often (46.9% vs. 57.1%, p<0.001) and radiation more often (23.8% vs. 13.8%, p<0.001). Conclusions: In this population-based sample, half of patients with low-risk LPC chose observation, with majority of these choosing AS. Treatment choice was associated with location and race.

P110 The Dissemination of Faith-Based Messages to Encourage Somali Women to Participate in Breast and Cervical Cancer Screening

Rebekah Pratt; Nimo Ahmed; Wali Dirie; Sharif Mohamad; Kola Okuyemi, MD, MPH

11/18/17 9:20 AM - 10:20 AM Sq Dorchester & Parc Mount Royal ABC

Background: Screening rates for breast and cervical cancer for Somali women in the US are low, and that is particularly the case for first generation immigrants. Somali women living in areas of economic disadvantage may have much lower rates, as low as 8% for mammography. There are many barriers that impact screening for Somali women, such as health literacy, access, and lack of knowledge about cancer. Some barriers have been identified as being based in interpretations of the Muslim faith, such as concerns about modesty, predetermination, along with attitudes to prevention. Working in partnership, we developed messages that explored faith based perspectives on screening, encouraged screening and addressed areas of concern for community members. Our aims were to share these messages, and assess the acceptability and impact of these messages, on Somali women who are eligible for breast and cervical screening, and with Imam, as faith leaders in the community. Methods: 30 Somali women participated in a workshop, where an Imam Sharif Mohamed shared a DVD of faith based messages, and led a discussion on cancer screening. 11 Somali Imam also participated in a workshop, where the faith based messages were discussed and they were encouraged to share the messages onward. Pre and post workshop surveys collected data on attitudes, views on the workshop and future screening intentions. Findings: Overall, the workshop was very well received. All 30 women who attended the workshop reported learning beneficial information, would recommend this workshop to a friend, and felt attending the workshop made it more likely that they would get screening. All 10 Imam reported learning useful information, finding the workshop enjoyable and would recommend it to a friend. 9/10 Imam planned to share the information in their own sermons in the future. The workshop appeared encourage positive changes in attitude towards breast and cervical cancer screening, with more of the women and Imam being likely to view the value of early screening, and fewer feeling that screening may cause harm, as shown in the post-workshop surveys. Conclusion: Faith based messages can be successfully shared in the community, and may help encourage breast and cervical cancer screening uptake. Including faith based messages in cancer screening efforts could offer more culturally relevant and meaningful content for Somali women, and help address the cancer disparities facing the community.

P111 Predictors of Colorectal Cancer Screening Prior to Implementation of a Large Pragmatic Trial in Federally Qualified Healthcare Centers

Thuy Le, MPH; Amanda Petrik; Erin Keast; Jennifer Rivelli, MA; Keshia Bigler, MPH; Beverly Green; William Vollmer; Gloria Coronado

11/18/17 9:20 AM - 10:20 AM Sq Dorchester & Parc Mount Royal ABC

Background: Colorectal cancer (CRC) screening can prevent cancer deaths. Federally qualified healthcare centers in the US (FQHCs) serve a patient population that often underscreened. Knowing who in the FQHC environment is getting screened, and how, can assist in tailoring intervention to increase screening. Methods: As part of the Strategies and Opportunities to STOP Colon Cancer in Priority Populations (STOP CRC) study, we examined characteristics associated with being up to date with CRC screening guidelines. We also examined associations between these factors and being screened with a fecal test. Results: We observed a steady rise in CRC screening rates from 2010 to 2015 (17.7%-46.8%). In adjusted analysis, factors associated with being up to date with CRC screening overall were: being older (>= 65 vs. <65), having health insurance, having prior office or emergency room visits, and being up to date with other screenings (pap, mammograms, flu shots). Among adults aged 50-75 who were up to date with CRC screening, factors associated with use of fecal testing, as opposed to colonoscopy, were: being younger, speaking a non-English language, being uninsured, having prior office visits, having had a flu shot in past year, and living in a neighborhood with higher unemployment. Conclusion: Encounter-level variables were most often associated with predicting CRC screening. FIT/FOBT use was more common among typically underscreened populations (i.e. younger, non-English speaking, uninsured). Our findings may inform clinic-based effort to raise rates of CRC screening, especially in the community clinic setting.

P112 Development of EXCELS: A Primary Care Focused Health-Coaching Program to Facilitate Engaged Self-Management for Cancer Survivorship Follow-up

Denalee O'Malley, MSW; Stacy Davis; Kelsey Lally; Katie Devine; Patricia Findley, DrPH, MSW; Lynn Clemow; Suzanne Miller, PhD; Shawna Hudson, PhD

11/18/17 9:20 AM - 10:20 AM Sq Dorchester & Parc Mount Royal ABC

Context: Long after active treatment ceases, patients with a history of cancer are seen in primary care contexts. Few tested strategies have been developed to optimize their engagement in follow-up and preventive health care. This study describes a patient-engaged development strategy for a tailored, telephone-delivered self-management program to provide Extended Cancer Education for Longer-term Survivors (EXCELS) of breast, colorectal and prostate cancers in primary care. Design: A qualitative, depth interview study. Setting: A purposive sample of cancer survivors and primary care physicians from the general community were interviewed to inform the EXCELS health coaching program development. Patients: Individual and dyadic interviews with breast (n=33), prostate (n=4) and colorectal (n=6) were conducted. Results: Clinical guidelines for each cancer site were reviewed and using health education best practices constructed into a manualized, paper-based self-management guide. A majority of patients reported interest in a tailored, goal-oriented health coaching program currently or earlier in their post-treatment experience. They wanted a range of guidance from a health coach, including the following areas: social support, information about late and long-term effects, goal-setting, reminders, and accountability. Of the patients who did not want access to a health coach, many cited not wanting to be pestered or that they had sufficient control over their health. Patients also reported different preferences in how they would engage a health coach, therefore, the health coaching program was designed so that patient goals would guide the program focus accordingly. Conclusions: Using an established theoretical framework and a patient engaged development strategy, a relationship-centered intervention that tailors self-management goals based on cancer site, time from treatment and salient patient concerns was developed allowing patients to control the timing of calls and the degree of accountability to their health coaches. Research to test the feasibility of this program in primary care settings is needed.

P113 The LEAD Study Protocol: A Mixed-Method, Observational Cohort Study Comparing the Lung Cancer Diagnostic Pathways Between Anglo-Australian Patients and Those From Culturally and Linguistically Diverse (CALD) Backgrounds

Danielle Mazza, MBBS, MD

11/18/17 9:20 AM - 10:20 AM Sq Dorchester & Parc Mount Royal ABC

Context and aims: Lung cancer is the leading cause of cancer mortality worldwide. Culturally and Linguistically Diverse (CALD) patients are especially vulnerable with higher mortality rates than Anglo-Australians. The LEAD study aims to explore differences in the lung cancer pathways from symptom appraisal to treatment between CALD and Anglo-Australian patients and factors underlying these differences. Methods: Informed by the Aarhus Statement, the LEAD study measures the lung cancer pathway through four key time intervals (appraisal, help-seeking, diagnosis, and pre-treatment intervals) It uses a mixed-method, observational cohort design and comprises patient symptom questionnaires, case-note analyses of hospital and general practice records, and interviews with patients, general practitioners and hospital specialists. Patients will be recruited from five cancer services in Melbourne, Sydney and Brisbane. LEAD is funded by Cancer Council Australia. Findings: The primary outcome is the length of the time intervals in the cancer pathway. Data will also be collected on cancer staging, patient variables (eg, demographics), practitioner variables (eg, GP billing practices), and health system variables (eg, involvement of a multidisciplinary team). Innovative contribution: LEAD will be the first study to provide comprehensive data on the lung cancer pathways of CALD and Anglo-Australian patients. It will also identify factors underlying the differences in the pathways between the two groups. Such information is vital for a multicultural country like Australia to understand ethnic disparities in health outcomes and will inform interventions aimed at improving health outcomes in lung cancer patients, particularly, CALD patients.

P114 Role of Primary Care in Cancer Survivorship: Survivor Perspective

Maresi Berry-Stoelzle; Jeanette Daly, PhD; John Ely, MD, MSPH

11/18/17 9:20 AM - 10:20 AM Sq Dorchester & Parc Mount Royal ABC

The number of cancer survivors in the United States is expected to increase from 13.7 million to 18 million in 2022 with a 37% increase in those living longer than five years from diagnosis. Cancer survivors’ follow-up care includes cancer and non-cancer related health concerns. The overall purpose of the project is to identify how a primary care provider can integrate cancer survivorship into routine patients care The purpose of this study was to gather themes important to cancer survivors on the role of the primary care provider in their medical care. 22 Adult cancer survivors at least 18 months after completion of cancer therapy, participated one of three focus groups. Focus groups were conducted by the PI, using a series of open-ended questions. A qualitative analysis was conducted to identify emerging themes using the constant comparison method. The study and methods were approved by the University of Iowa IRB. Themes identified included patient engagement and access, provision of care by the primary care provider during treatment and after treatment, patients’ perceptions of communication between primary care provider and oncologist, transition from oncologist, complications, and late effects. The survivorship process was complex and often challenging. Continuing physical symptoms were both potential sequelae from the malignancy and therapy as well as evaluation of any new symptoms. Cancer survivors were concerned about own mental health, as well as the mental health of their support network. There are many general themes; there is significant individual variation within each theme in how a particular survivor would like their survivorship structured. Adapting survivorship care to a given patient is essential work for primary care providers. As patients disengage from their cancer provider, primary care is an important touch point in the medical system and continues to be important in managing their cancer survivorship.

P115 Cancer Survivorship in Primary Care: A Mixed Methods Comparative Study of Contextual Features of Care Across Three States

Autumn Kieber-Emmons, MD, MPH; William Miller, MD, MA; Benjamin Crabtree, PhD; Jenna Howard, PhD

11/18/17 9:20 AM - 10:20 AM Sq Dorchester & Parc Mount Royal ABC

Context: Cancer survivorship care is a growing primary care need as cancer clinical outcomes improve alongside an expanding and aging population. Given the complexity of chronic care management for cancer survivorship, multi-level research and interventions are necessary to understand how to provide better survivorship care. Objective: To identify potentially modifiable community, medical and policy level contextual elements that aid or inhibit delivery of optimal cancer survivorship care. Design: A mixed methods comparative case study design, embedded within a larger national R01 study of cancer survivorship in primary care. GIS technologies and qualitative depth interviews of local key informants were used to evaluate three levels of the socio-ecologic model - community, medical and policy - around primary care practices' neighborhoods. Setting: Seven counties located in three states, Colorado, New York and Maine, served as the case studies. Patients or Other Participants: Purposefully sampled key informants from each of the three neighborhood levels were consented to participate in telephone interviews. A total of 22 key informants participated across the seven counties. Intervention/Instrument: NA Main and Secondary Outcome Measures: Identification of potentially modifiable community, care delivery (medical) and policy features that are barriers or facilitators to high quality cancer survivorship care. Results: Three state GIS maps show regional differences in insurance and cancer mortality rates. Additionally, a 3 by 7 matrix with results from the 22 transcribed interviews shows themes that are regionally relevant and others that are relevant across regions. For example, themes included are: rural counties have issues with survivorship follow-up given travel distances, and all regions identified communication and coordination between oncologists and PCPs as an area for improvement in order to optimize survivorship care. Conclusions: Final analysis will hopefully lead to identification of potentially modifiable contextual elements that could be targets for interventions and policy change.

P116 Decision Support and Navigation to Increase Colorectal Cancer Screening Among Hispanic Primary Care Patients

Randa Sifri, MD; Melanie Johnson, MPA; Beth Careyva, MD; Brian Stello, MD; Constantine Daskalakis,, ScD; Melissa DiCarlo, MPH, MSc; Evelyn Gonzalez, MA; Sarah Hegarty; Alicia Rivera; Lucas Gordils-Molina; Kyle Shaak, MPH; Anna Quinn, MPH; Rosa Anderson-deOrtiz; Ronald Myers, PhD

11/18/17 9:20 AM - 10:20 AM Sq Dorchester & Parc Mount Royal ABC

Context: Colorectal Cancer (CRC) screening rates are much lower among Hispanics than non-Hispanic Whites and African Americans. Objective: The study compared the impact of a novel decision support and navigation intervention (DSNI) to a mailed standard intervention (SI) on CRC screening among Hispanic patients. Design: Randomized control trial Participants: Hispanic patients who were 50 to 75 years of age from 5 primary care practices in the Lehigh Valley Health Network, and were eligible for CRC screening Intervention: Participants were randomized either to an SI Group (n=200) or a DSNI Group (n=200). Following randomization, SI Group participants were mailed a set of standard materials (i.e., a letter from the participant’s primary care practice encouraging selection and performance of either colonoscopy screening or a stool blood test (SBT), a SBT kit, and instructions for arranging a colonoscopy appointment). Print materials were provided in English and Spanish. DSNI Group participants were also mailed the standard materials. In addition, participants received a telephone call from a bilingual patient navigator who reviewed the screening materials and verified the participant’s preferred CRC screening test. During the call, the patient navigator also used an online Decision Counseling Program© (DCP) to determine the participant’s likelihood of test performance and to develop/navigate a personal test performance likelihood-based screening plan. The plan was mailed to the participant and their primary care practice; and a screening status report was sent to each patient’s practice at 6 months. Finally, a 6-month survey was targeted to participants in both study groups. Outcome Measures and Results: Based on 6-month survey and medical records data, we found that CRC screening adherence was significantly higher (OR=3.48, CI: 2.29, 5.29, p<0.001) in the DSNI Group (73%) versus the SI Group (44%). Conclusions: A decision support and navigation intervention significantly increased CRC screening adherence among Hispanic patients.

P117 Group Learning Activity as Preamble to Practice Engagement for a Transformation Initiative: A Heart of Virginia Healthcare Report

Anton Kuzel, MD, MHPE; Virginia Brooks; Alison Cuellar, PhD; Christine Sinsky, MD

11/18/17 9:20 AM - 10:20 AM Sq Dorchester & Parc Mount Royal ABC

Background: As part of the AHRQ Evidence Now Initiative, the Heart of Virginia Healthcare collaborative recruited 249 practices to engage in practice redesign followed by improvements in cardiovascular care. Our intervention had three phases: a kickoff meeting attended by two representatives from participating practices, a 3-month intensive coaching phase, and 9 additional months of practice support from our coaches and physician faculty. The kickoff meeting featured presentations on simple strategies for practice redesign, on the evidence for current guidelines regarding cardiovascular care, and on improving personal and group resilience. We are interested in whether those practices that chose to attend the kickoff meetings showed other important differences on indicators of practice engagement in the subsequent intervention phases. Methods: We compared practices that attended the kickoff meetings vs. those that didn’t on the following characteristics and indicators: • Practice characteristics • ABCS performance at baseline • Adaptive reserve scores at baseline • Coach-rated level of engagement • Number and kinds of coach touches Results: [Will be available at the time of the meeting] Discussion: This will depend on the results, but based on reports from our coaches, those practices that attended the kickoff showed more engagement and readiness to change than those practices that didn’t attend the kickoff. This is more likely an indication of self-selection of practices with regard to kickoff attendance, but nonetheless it suggests that our kickoff content provided a good "running start" for practices already motivated to change and improve.