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2018 NAPCRG Annual Meeting

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PR1 Place Matters: Mapping and Data Tools for Doing Population Health

Michael Topmiller, PhD; Mark Carrozza; Jené Grandmont; Jennifer Rankin, PhD; Andrew Bazemore, MD, MPH

11/9/18 8:30 AM - 12:30 PM Stevens Salon C2

Objectives: This 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

PR2 Learning From the Experienced: Tips and Tricks for Enhancing PBRN Research

Hazel Tapp, PhD; Rowena Dolor, MD, MHS; Katrina Donahue, MD, MPH; Donna Manca, MD, MCLSC; Maeve O'Beirne, MD, PhD

11/9/18 9:00 AM - 12:00 PM Stevens Salon C3

Content: The session will start with a brief overview, where workshop leaders present a short outline of their own PBRNs to set the context and stimulate subsequent discussion. Discussion will be based on the needs of the participants. During the course of the session, both the workshop leaders and the attendees will share strategies and examples from their experience of being part of a PBRN.

PR3 Involving Patients, Practitioners and the Public as Research Partners

Jon Salsberg, PhD; Joseph LeMaster, MD, MPH

11/9/18 9:00 AM - 12:00 PM Stevens Salon C7

Content: Method and Schedule: We will use a combination of workshop activities, worksheets and roleplaying exercises. Activities will be co-facilitated by researchers and PaCE partners. Participants will share, discuss and comment on each other’s partnerships. Prerequisite Knowledge: Participants should already be familiar with how to design a standard (i.e., non-engaged) research project. Participants can come prepared whith their actual research topic to work through, or can use an imagined one. Materials that will be made available in advance of the course: Partner Identification Worksheets

PR4 How to Get High Quality Evidence from Observational Studies: Design, Analysis, Interpretation and Reporting Considerations

Miguel Marino, PhD; Claire Godard-Sebillotte, MD; Sathya Karunananthan; Christopher Morley, PhD; Nadia Sourial, MSc; Tyler Williamson, PhD

11/9/18 9:00 AM - 12:00 PM Stevens Salon C8

In primary care, randomized trials are often viewed as the gold standard for determining the causal effect of interventions. However, practice-based interventions, quality improvement studies or system-wide policies can rarely be evaluated using randomized trials, as randomization is often inappropriate or infeasible for many practical, logistical or political considerations. With the advent of practice-based research networks, and increased connectivity of electronic health records and health administrative data, primary care research has a tremendous opportunity to answer important primary care questions using observational data sources. The validity and practical utility of observational research to inform primary care depends critically on appropriate study designs, outstanding data quality, suitable statistical methods, and accurate interpretation of results. This half-day course will provide accessible guidance for researchers with different levels of quantitative expertise in the analysis of observational studies. Upon completing this workshop, learners will be able to: (a) describe common study designs used in observational studies, (b) compare different statistical methods used in particular designs, (c) contrast different measures of association and understand how to accurately report them, (d) identify potential biases commonly found in observational studies and methods for addressing them, and (e) critically evaluate observational primary care studies.

PR5 Economic Evaluation Methods for Primary Care Research and Practice Improvement

Richard Young, MD

11/9/18 1:00 PM - 4:00 PM Stevens Salon C8

Content: The workshop will present key concepts and methods in economic evaluation in health care, along with concrete examples of their application. The discussion will include how these are applied when comparing outcomes between different practice models and approaches. As well, the workshop will entail applied exercises. Participants will come away with a greater fluency in economic evaluations and a better understanding of the application of these approaches in primary care. Method and Schedule: Ideally, the workshop will be 120 minutes and provide a combination of presentations and small group work on practical exercises that apply the concepts and methods covered in the presentations. For the first 40 minutes, the expert presenter cover the key concepts in economic evaluations – e.g., cost-effectiveness, cost-utility and cost-benefit analyses. The next third of the workshop, will involve discussions and exercises related to measuring costs and outcomes applied in economic evaluations. Finally, the workshop will cover applied examples of the various economic evaluation methods, including an exercise that entails critically assessing published health economics articles. Prerequisite Knowledge: None required, though the participant will get more out of the workshop if he or she watches 3 webinars the CA Workgroup produced. See below. Materials that will be made available in advance of the course: 3 webinars available at: http://www.napcrg.org/AboutUs/Committees/CommitteeonAdvancingtheScienceofFamilyMedicine-CASFM/CostAnalyses.

PR6 Building and Using an EHR to Facilite Patient-Physician Relationships

Cynthia Sieck, MPH, PhD; John Beasley, MD; Brian Henriksen, PhD; David Mehr, MD, MS; Gerald Pulver, PhD, MPH; Amanda Terry, PhD

11/9/18 1:00 PM - 4:00 PM Stevens Salon C7

Content: This workshop will discuss: •The importance of patient-physician relationships •Current challneges in the use of EHRs •Policies that hinder or facilite establishing good patient relationships •Physcian burnout associated with EHR use and it’s impact on the relationship with patients •Potential additional training needs related to using EHRs in a manner that facilitates relationship building •Methods for including patients in understanding the impact of EHR use on the patient-physician relationship •Specific needs of primary care physicians related to EHRs and patient relationships •Setting an agenda to improve EHR use to facilitate patient relationships Method and Schedule: This ½ day workshop will utilize a focused discussion format. Leaders will present the a conceptual model of how EHRs impact the patient-physician relationship followed by a discussion related to the model. Break out groups will the discuss specific elements of the model and report their discussion the group. We will conclude with a session summarizing modifications to the conceptual model. Prerequisite Knowledge: Some knowledge of use of EHRs and medical training. Materials that will be made available in advance of the course: Conceptual outline of issues related to the workshop focus.

PR7 100 Years Beyond Flexner: EBM, Information Mastery, and Shared Decision-Making

Allen Shaughnessy, PharmD, MMedEd; Roland Grad, MD, MSc, CCFP, FCFP; Charo Rodriguez, MD, MSc, PhD; David Slawson, MD

11/9/18 1:00 PM - 4:00 PM Stevens Salon C3

Content: •Brief history of changes in medical education (pre-Flexner, Flexner, risk of EBM, rise of teaching clinical reasoning) •Brief intro to the concepts of evidence-based medicine, information mastery, and shared decision making concepts •Introduction of the probability model in medical care (from rationalism to empiricism) •Challenges to teaching and using shared decision making •Opportunities for medical education research that spans EBM, information mastery, clinical reasoning, risk communication, and shared decision making Prerequisite Knowledge: Basic understanding of evidence-based medicine concepts and practices Materials that will be made available in advance of the course: All registered attendees will be given access to two online modules that explain the framework: “Evidence-Informed Decision Making: An Introduction; and, Evidence-Informed Decision Making: Safety, Quality, and Evidence), as well as several other, related modules developed by two of us (at clinicalinformationsciences.com)

PR8 Getting Your Message Out There: Tools and Approaches to Reach Non-Academic Audiences

Nicole Porter; Adam Pike; Andrea Pike, MSc; Sara O'Reilly, BA, MASP; Kris Aubrey-Bassler, MSc, MD

11/9/18 1:00 PM - 5:00 PM Stevens Salon C2

Objectives: In this session, attendees will learn how to effectively document research information and display study findings in easily digestible formats suitable for non-academic, non-researcher audiences (e.g. policymakers, clinicians, patients). Rationale: Knowledge translation and dissemination is an important part of any research project; if research findings are not shared, opportunities for synergistic collaboration with policymakers and uptake among clinicians are lost. However, primary care research is often conducted with limited funds, restricting researchers’ ability to engage professional services to generate the most effective KT and dissemination materials, reducing potential reach. Moreover, output is often ineffectively adjusted to suit its target audience, compounding the issue. Participation: Attendees will work together to develop mock research findings documents targeted toward a specific non-academic audience, based on skills and knowledge delivered throughout the workshop. Feedback from attendees will be strongly encouraged throughout, especially where non-researchers can provide valuable input. Prerequisite Knowledge: None.

P101 The Provision of Integrated Behavioral Health Within Employer Based Insurance: Policies for Improved Population Health

Larry Green, MD; Sarah Hemeida, MD; Alison Shmerling, MD, MPH; Emma Gilchrist, MPH; Shale Wong, MD

11/10/18 9:30 AM - 10:30 AM Stevens Salon B

Context: The growth of integrated behavioral health services has challenged both public and private payers to adapt their traditional fee-for-service payment models, which prioritizes and separates the funding streams for physical health services from behavioral health services. EBI provides insurance coverage to 50% of the Unites States population. Integrated BH services are widely known to be an effective and efficient means to achieve whole person health and is slowly gaining increased representation among EBI benefits. Objective: To identify the mechanisms of payment within EBI for behavioral health services. Study Design: Rapid review of the literature using Ovid MEDLINE and PsycInfo for peer-reviewed studies and Google for grey literature. Additional articles identified via snowball method and expert recommendation. Combined, 470 articles retrieved; after applying inclusion and exclusion criteria, 161 articles included in the review. Results: Federal mandates for BH parity is largely unenforced due to exemptions and loopholes. There are small EBI pilot programs which are exploring alternative payment mechanisms including global payments, procedural billing codes, and public-private partnerships to provide integrated BH services. Conclusions: EBI has largely failed to achieve parity for BH services. State level regulations have proven effective policy levers to increase BH access to beneficiaries. The unique and centralized nature of EBI to determine, administer, and pay for benefits allows them to easily and quickly adjust patient access and utilization. Successful EBI pilot programs providing alternative payment mechanisms for integrated behavioral health services could be moved to scale to improve employee and population health, if desired.

P102 Aligning the Education and Healthcare Sectors: The Role of Integrated Behavioral Health to Make Health Whole

Shale Wong, MD; Christina Yebuah; Emma Gilchrist, MPH; Hilary Stempel, MD

11/10/18 9:30 AM - 10:30 AM Stevens Salon B

Context: Adolescent behavioral health concerns are common and cause significant morbidity. Less than 30% of youth with behavioral health struggles receive services. But, of those that do, most receive them in the school setting. Primary care providers have an essential role in identifying youth with behavioral health problems and partnering with schools and community resources to ensure youth have access to needed services. Objective: Identify policy levers to enhance coordinated care among schools, community, and primary care for youth at risk for and with behavioral health concerns. Study Design:Rapid review of gray literature and peer reviewed literature. Additional articles identified via the snowball method and expert recommendation. Combined, 1,355 articles retrieved; after applying inclusion and exclusion criteria, 48 articles included in the review.Dataset: Ovid Medline, PsycInfo and gray literature through Google. Patients or Other Participants: All school-aged children, focusing on adolescents. Main and Secondary Outcome Measures: Using the Multi-Tiered Systems of Support (MTSS) offers opportunity for aligning missions of school and primary care around adolescent behavioral health by establishing a framework for communication and partnership. The MTSS framework incorporates tiered behavioral health supports: universal supports for all and tiered, more intensive services for students with greater need. Conclusions: To integrate behavioral health for adolescents in schools and primary care necessitate partnership at each tier of the MTSS. Utilizing MTSS as a common framework prioritizes collaboration by ensuring clear bidirectional communication that complies with Health Insurance Portability and Accountability Act and Family Educational Rights and Privacy Act. Furthermore, the MTSS framework encourages leveraging diverse funding streams for appropriate reimbursement. Using evidence-informed programs and services with a data-driven evaluation approach will further guide in building systems to support whole health of adolescents.

P103 Use of Monetary Incentives to Increase Access to Medication Assisted Treatment for Opioid Use Disorder in Colorado

Kyle Knierim, MD; Sandra Ruland, DVM, MS; Daniel Pacheco; Kristen Curcija, MPH; Rebecca Mullen, MD, MPH; Linda Zittleman, MSPH

11/10/18 9:30 AM - 10:30 AM Stevens Salon B

Context: Office based opioid treatment using medication assisted treatment (MAT) is an effective strategy to treat Opioid Use Disorder (OUD), but few providers have completed the mandatory DEA waiver training required to legally prescribe MAT for OUD. Objective: Describe the results of using modest monetary invectives to increase MAT access in Colorado. Design: Cross-sectional descriptive study. Setting/Participants: Colorado providers (MD, DO, NP, PA), of any specialty, with active prescribing authority who applied for monetary incentives through the IT MATTTRs2 program. Intervention: Monetary incentives offered to participating providers, or their employers, with proof of waiver training curriculum completion on a first-come, first-served basis. Additional incentive given after applying for DEA X waiver. Outcomes: Participating provider demographics, including gender, specialty, and practice location. Secondary outcomes included provider knowledge and attitudes towards OUD and OUD treatment activities. Results: 282 providers received monetary incentives for completing the MAT curriculum in the first 9 months of the program. 197 (69%) also applied for their DEA X waiver. A majority of participants were female (61%), MD’s (55%) aged 25-34 (55%), located in urban areas (93%), and practiced in hospital/health system or residency practices (25% and 27.8% respectively). The most common specialties were Family Medicine (n=129, 45%), Psychiatry (n=57, 20%), Internal Medicine (39, 13.7) and Emergency Medicine (n=31, 10.9%). Providers considered heroin use to be a very serious problem for their patients less often than opioid use (28.6% vs 48.2%, p <0.0001). They reported that their practices were screening for behavioral health conditions more than OUD (82.4% vs 46.4%, p <0.0001). The 169 providers who completed a 3 month follow up survey reported providing MAT to 249 new patients. Conclusion: Monetary incentives provided to providers or employers may be an effective way to increase access to MAT across a state.

P104 Utilization of EHR in Screening and Management of Depression Associated With Better Resident Training and Patient Care

Shashank Kraleti, MD; Nicola Edge, PhD; Diane Jarrett, EdD; Lorraine McKelvey, PhD; Jack Sublett II, MD; Ian Bennett, MD, PhD

11/10/18 9:30 AM - 10:30 AM Stevens Salon B

Context: Screening and management tools in the Electronic Health Record (EHR) can be useful for Family Medicine physicians in caring for patients with depression. Family Medicine residency programs that incorporate such tools in their training lay the groundwork for future physicians to diagnose and manage depression in a comprehensive fashion. Objective: Examine the utilization of the EHR in Family Medicine residency training on screening and management of depression and its effect on consistency of patient care. Study Design: Survey. Setting or Dataset: Used survey data gathered through the 2017 Council of Academic Family Medicine’s (CAFM) Educational Research Alliance (CERA) national survey of family medicine PDs. Participants: PDs in ACGME accredited Family Medicine residency programs. Main Outcome Measures: Ten items were designed and used to capture the practices of Family Medicine residency programs in training their residents to diagnose and manage depression, including with the assistance of EHR tools and reminders. Results: The response rate was 57.1%, with the survey being completed by 298 PDs who were majority male (58.9%) and White (83.8%) with an average of 7.06 years of experience as PD. Significant associations were found between the integration of depression screening/management monitoring into the EHR and the consistency and comprehensiveness of the approach to screening and management of depression in the clinic where residents train. For example, when screening/management of depression is not integrated into EHR, 61% of PDs report a clinic process to screen all adult patients consistently. This increases to 72.9% if screening is integrated into EHR and 87.8% if screening and management is integrated χ2 (2, N = 286) = 18.81, p < .001. Conclusion: Family Medicine residency programs that integrate screening and management of depression into the EHR are more likely to consistently screen all patients for depression and appropriately manage depression, including maternal depression.

P105 What Should I Have Done Better?

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

11/10/18 9:30 AM - 10:30 AM Stevens Salon B

Background Many general practitioners (GPs) find the care for patients with medically unexplained symptoms (MUS) challenging and struggle with consultations with patients with unexplained symptoms Aim We aim to identify GPs’ difficulties in the communication with patients with unexplained symptoms to improve communication between GPs and patients with unexplained symptoms. The CATMUS study. Methods We video-recorded all consultations during 1-2 days and asked the GPs immediately after the consultation whether unexplained symptoms were presented. The GPs were asked to reflect on these consultations during a semi-structured interview while watching a recording of the consultation. The interviews were recorded and analysed qualitatively according to the principles of constant comparative analysis. Results Of the 393 video-recorded consultations, 43 concerned unexplained symptoms. GPs identified four main themes of difficulties in which they indicated there is room for improvement. First, GPs mentioned they have to pay more attention to a thorough of the symptom. Second, GPs indicated they have to focus more on the structure of the consultation. Third, GPs found they should be more aware of being person-centered by giving more attention to the patient’s agenda and by improving the quality of the communication. Conclusion The participating GPs stated that they can improve their consultations with patient with unexplained symptoms. We will combine the results of this study with the results of studies with patients to construct a communication tool for GPs.

P106 Knowing the Life Story Improves the Doctor-Patient Relationship

Lewis Mehl-Madrona; Jessica Bloom-Foster, MD; Patrick McFarlane, MSW, MA, MSN

11/10/18 9:30 AM - 10:30 AM Stevens Salon B

Context: Narrative medicine is growing within family medicine and predicts that knowledge of the lives of patients should improve the doctor-patient relationship. Research supports better doctor-patient relationships leading to improved medical outcomes. The aim of this study was to determine if this would occur in a residency teaching clinic setting and if improved doctor-patient relationships would be associated with reductions in anxiety, severity of depression, and/or degree of pain among patients. Objective: To determine if sharing the patient’s life story with his/her primary physician will improve each one’s ratings of their relationship, and secondarily, if this will be associated with reductions in anxiety, severity of depression, and level of pain, and if patients would accept such interviews and how they would feel about these interviews being part of their care. Study Design: Quasi-experimental trial with baseline and repeated measures quarterly for one year after the intervention. Setting: A rural, northern New England family medicine residency teaching clinic serving primarily a lower socioeconomic, publically funded clientele. Patients: Those having a disorder involving pain selected through convenience sampling. Intervention/Instrument: The Northwestern University Life Story Interview conducted after patients and their physicians completed the Doctor-Patient Relationship Questionnaire, the Center for Epidemiological Studies Depression Inventory, the McGill Pain Inventory, and the Zung Anxiety Inventory. Main and Secondary Outcome Measures: Change in the rating of the doctor-patient relationship. Secondary: Changes in pain, anxiety, and depression levels. Results: Patients’ ratings of their relationship with their physicians and physicians’ ratings of their relationship with their patients improved after the life story interview (p < 0.01). Pain levels decreased (p <0.05) as did anxiety (p < 0.05) and depression (p < 0.05). Patients enjoyed participating in the interviews and physicians were surprised by details in the life story and believed that they could take better care of their patients through knowing those details. Conclusions: Knowing more details of patients’ lives is associated with improvement in the doctor-patient relationship and reduction in symptoms of anxiety, pain, and depression, whose levels otherwise worsen over time in our setting. Further research is indicated with random assignment and a control group.

P107 Exemplary Behavioral Health Integration: Characteristics of SIM Practices

Rebecca Mullen, MD, MPH; Sandra Ruland, DVM, MS; Lauren Shviraga; Douglas Fernald, MA; Kyle Knierim, MD; Perry Dickinson, MD

11/10/18 9:30 AM - 10:30 AM Stevens Salon B

Context: The Colorado State Innovation Model (SIM) funded by the Center for Medicare and Medicaid Innovation supports primary care practices in preparing for advanced payment models with a particular emphasis on integrating behavioral health. Exemplar methodology is a useful tool to comprehend complex constructs. Efficiently identifying high-performing practices may facilitate idea dissemination, scaling efforts, and overall improvement of health outcomes and systems. Objective: To identify and characterize exemplary SIM-participating practices as it relates to integrated behavioral health. Design: Quality improvement analysis. Method: Area-under-the-curve analysis of Comprehensive Primary Care Practice Monitor (Monitor), depression-related Clinical Quality Measures (CQMs), and Integrated Practice Assessment Tool (IPAT), after one year of practice transformation support. Setting: 92 primary care practices in cohort 1 of SIM. Outcome Measures: Exemplar practices were defined by the following three measures: IPAT Level 6 (indicating full integration/collaboration), 75th percentile or higher in adult/adolescent and maternal depression CQM screening, and 75th percentile or higher in the Behavioral Health Integration subdomain of the Monitor. Results: Among 92 practices, nine were identified with exemplary behavioral health integration. Exemplar practices were more likely to serve both pediatric and adult populations (67% vs. 18%, p<.005) and more likely to report a higher average number of clinicians (19.4 vs. 7.9, p<.0001). BH-domain Monitor scores increased over time (p=.05), but there was a more significant increase in exemplary practices’ scores over time (+11.7 vs +.6, p=<.0001). There was no significant difference in ownership, payer mix, PCMH certification, urban vs. rural location, burnout status or overall performance on the Monitor between exemplar and non-exemplar practices. Conclusion: This study suggests that larger practices serving both pediatric and adult patients are more likely to have exemplary behavioral health integration as measured by a mixture of an integration assessment tool, practice monitor, and commonly-reported CQMs. This may provide a practical approach to identifying practices with exceptional behavioral integration efforts and assist other practices in integration activities.

P108 What Health Goals Do People With Chronic Health Conditions Want to Work On?

Emily Spence-Almaguer, PhD; Scott Walters; Whitney Mollenhauer; Shlesma Chhetri

11/10/18 9:30 AM - 10:30 AM Stevens Salon B

Context: Medical practice largely focuses on disease-based outcomes for specific conditions. However, this orientation may be ill suited for people who have multiple or chronic health conditions. Furthermore, this focus may not address patients’ most important health priorities. We examined the behavioral health goals set by people with different chronic health conditions. Participants were low-income housing residents with mental health conditions who were participating in a health coaching intervention. Objective: This presentation will examine the relationship between chronic health conditions reported by patients and the behavioral health goals they chose during the program. Study Design: Descriptive. Setting: A health coaching intervention provided in an urban setting to people who were formerly homeless and now residing in supportive housing. Eligibility criteria included being on Medicaid or being uninsured and having a mental health condition. Main and Secondary Measures: Measurements include self-reported chronic health conditions and health goals based on a qualitatively-coded analysis of goal statements written by participants and their health coaches. Results: Of 576 total participants at baseline, 522 (91%) reported having one or more chronic health conditions. The most common conditions were arthritis/joint pain (64%), back or neck disorders (53%), heart or circulatory conditions (53%), allergies (52%), breathing disorder/emphysema (34%), stomach or bowel disorder (30%), migraines (29%), asthma (25%), and diabetes (22%). On average, participants set 5.9 health goals during their time in the program. People with stomach disorders, migraines, back pain, and heart problems were less likely to set goals associated with self-sufficiency (such as employment and obtaining critical documents). People with diabetes were more likely to set goals associated with diet, weight loss, and health self-management. Smoking reduction was more likely to selected by people with breathing disorders, asthma and stomach/bowel problems. Conclusions: Understanding how patients’ goals relate to their health conditions can help inform patient-centered care approaches.

P109 Informed Decision Making in Lung Cancer Screening

Heather Bittner Fagan, MD; Ronald Myers, PhD; Nicole Harrington; Anett Petrich, RN, MSN; Claudine Jurkovitz; Mauren Wood; Zugui Zhang; Nora Katurakes; Cynthia Griffin; Roger Kerzner

11/10/18 9:30 AM - 10:30 AM Stevens Salon B

Context: The United States Preventive Task Force (USPSTF) recommends use of low dose CT scans (LDCT) for lung cancer screening in high risk individuals. The Center for Medicare and Medicaid Services (CMS) covers LDCT but requires shared decision-making. Primary care physicians will need to implement high quality shared decision-making for LDCT, and other medical decisions, into real world clinical practice. Objective: To test the feasibility of a telephone-delivered online decision tool to facilitate shared decision making regarding LDCT in primary care. Study Design: Uncontrolled cohort, pre/post analysis Participants/Setting: Current and former smokers meeting USPSTF eligibility for lung cancer screening identified using electronic medical record (EMR) data from a large, single primary care practice in Delaware. Main outcome measure: Lung cancer screening at 90 days measured by medical chart audit Secondary outcome: Decisional conflict measured by self-report at 30 days. . Intervention: A trained decision counselor contacted participants by telephone and completed a decision counseling session using an online software application, the Decision Counseling Program © (DCP) to clarify preference for LDCT screening and identify factors explaining preference. Results: From a pool of 297 smokers and former smokers, we identified 58 eligible individuals and enrolled 28 participants, including 19 current smokers and 9 former smokers. Participants who completed the DCP were more likely to complete LDCT screening (p=0.03). Current smokers were more likely to complete the DCP program compared to former smokers (p=0.02). Conclusions: The DCP is feasible for decision making, can be implemented without disrupting clinical care and promotes lung cancer screening. Best practices for implementing shared decision-making and increasing LDCT in real world clinical care are needed.

P110 The Three National Cancer Screening Programmes in the Netherlands Reviewed

Thom Bongaerts, MD; Frederike Buchner, PhD; Barend Middelkoop; Onno Guicherit; Mattijs Numans, MD, PhD

11/10/18 9:30 AM - 10:30 AM Stevens Salon B

Context: In the Netherlands there are three national population based cancer screening programmes (CSPs). These programmes concern breast, cervical and colorectal cancer. Each of these CSPs has its unique procedures and organization. Objective and Study Design: The aim of this systematic review was to provide an overview of the three CSPs in the Netherlands and compare their attendance rates, specifically looking at low attendance groups and their characteristics. Data source: A literature search in the databases Academic Search Premier, Cochrane Library, Embase, Emcare, Pudmed, PsycInfo, as well as grey literature was conducted, including all articles before October 2017. Studies: Search terms included: screening, cancer, participation and Netherlands. Returned articles were independently selected and reviewed by the first two authors. Outcome Measures: Primary outcome was attendance rate. Secondary outcomes were low attendance groups and their characteristics, including: health literacy, decision making or social and/or cultural differences. Results: In total 19 of the 1232 identified studies were included. Latest published CSPs attendance rates are 77.6%, 64.4% (2015) and 73% (2016) for respectively breast, cervical and colorectal cancer. Compared to previous years a mild declining trend can be observed in the two long-lasting programmes (breast and cervix). Low attendance is especially seen among non-western migrants, low-SES groups, residents of urban areas, younger age groups and males. Reasons for non-attendance can be found in the medical, practical and emotional/cultural domain. A family practice-based invitation is associated with higher uptake. Conclusions: Cancer screening programmes in the Netherlands have high attendance rates in general. Nevertheless, a declining trend is seen and uptake is different among subpopulations and regions. Present communication strategies insufficiently reach subgroups and the role of the general practitioner is becoming more marginal despite several studies advised the opposite. Future research should focus on identifying attendance barriers for subgroups and to implement tailored interventions.

P111 Provider Perspectives on Evidence-Based Interventions to Increase Colorectal Cancer Screening in Federally Qualified Health Centers

Allison Cole, MD, MPH; Elizabeth Medeiros; Peggy Hannon; Thuy Vu; Roxane Waldron; Victoria Gawlik

11/10/18 9:30 AM - 10:30 AM Stevens Salon B

Context: Selected federally qualified health centers (FQHCs) are funded by Washington’s Colorectal Cancer Control Program (WA CRCCP) to implement Community-Guide recommended evidence-based interventions (EBIs) to increase colorectal cancer screening. Several EBIs impact provider workflows and patient encounters. Provider feedback about EBIs will inform future implementation efforts. Objective: Assess provider knowledge and attitudes about their health system’s EBIs to increase CRC screening. Study Design: Cross-sectional survey. Setting: Two WA CRCCP supported FQHC systems. Organization 1 operates 29 clinics. Organization 2 operates six clinics. Participants: Primary care clinicians who provide care to patients aged 50-75. Procedure: The survey included multiple choice and short answer questions; it was administered electronically using REDCap. Participants had 2-4 weeks to complete the survey. We used descriptive statistics to characterize responses and thematic analysis to code and analyze qualitative data from open-ended responses. Main and secondary Outcome Measures: Proportion of respondents who agree that CRC screening processes and workflows have improved since implementation of EBIs, who report being more likely to talk with patients about CRC screening as a result of specific EBIs, and who are satisfied with the mailed fecal immunochemical test (FIT) program. Results: 64/185 (34%) providers completed the survey. 67% of respondents in Organization 1 and 54% of respondents in Organization 2 reported that CRC screening processes and workflows had improved since EBIs had been implemented. 91% of respondents reported increased CRC screening discussions as a result of provider reminders, while 65% reported an increase as a result of provider assessment and feedback. Conclusions: Responding providers reported increased CRC screening discussions with patients because of EBIs. Because a strong provider recommendation is an important predictor of CRC screening completion, this suggests that EBI implementation in the WA CRCCP is effective. However, there was variation across EBIs and between FQHC organizations that needs further exploration.

P112 The Association Between Cigarette Smoking, Cancer Screening, and Cancer Stage in the Women’s Health Initiative Observational Cohort

Victor Eng; Sean David, MD, DPhil; Shufeng Li; Mina Ally; Marcia Stefanick, PhD; Jean Tang, MD, PhD

11/10/18 9:30 AM - 10:30 AM Stevens Salon B

Context: Few population-based studies have assessed the dose-dependent relationship between smoking history and cancer screening rates or staging of cancer diagnoses. Objective: To evaluate the association of smoking with cancer incidence and cancer stage in postmenopausal women. Design: Prospective cohort study. Setting/Participants: 89,058 postmenopausal women from the Women’s Health Initiative (WHI) Observational Study aged 50-79 and recruited from 40 academic medical centers across the United States between 1993 and 1998. Patients with prior cancers were excluded. Smoking exposure was recorded at study entry and cancer cases were abstracted from annual follow-up surveys. Outcome Measures: Logistic regression models were used to assess the odds of obtaining breast, cervical, and colorectal cancer screening as stratified by smoking status. The odds of early- and late-stage cancer diagnoses among patients with inadequate screening were also calculated. Results: Over an average of 7.85 years of follow-up, current smokers had lower odds of obtaining breast (OR 0.49; 95% CI: 0.51-0.59), cervical (OR 0.53; 95% CI: 0.47-0.59), and colorectal cancer (OR 0.71; 95% CI: 0.66-0.76) screening. Former smokers were more likely than never smokers to receive regular screening services. Failure to adhere to screening guidelines resulted in diagnoses at higher cancer stages among current smokers for breast cancer (OR 2.78; 95% CI: 1.64-4.70) and colorectal cancer (OR 2.2556; 95% CI: 1.007 - 5.0535). Conclusions: Active smoking is strongly associated with decreased utilization of cancer screening services and more advanced cancer stage at the time of diagnosis. Clinicians should emphasize the promotion of both smoking cessation and cancer screening for this high-risk group.