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Armin Shahrokni


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  • 1. Armin Shahrokni Dr. Hee-Soon Juon May 2010 Johns Hopkins Bloomberg School of Public Health
  • 2. Significance of Topic Age-Adjusted U.S. Death Rates and Trends SEER data 1975-2006
  • 3. Analysis of air contrast barium enema, computed tomographic colonography, and colonoscopy: prospective comparison . Lancet 2005 Five-year Relative Survival Rates Among Patients Diagnosed with CRC by Race and Stage at Diagnosis, United States, 1996-2004. *Colonoscopy is an effective screening measure *Earlier diagnosis will lead to better survival Significance of Topic
  • 4. Significance of the Topic Rate of Adherence: Far from Ideal MMWR Morb Mortal Wkly Rep. 2008 Mar 14;57(10):253-8
  • 5. Barriers to Access Provider Practices, Knowledge, Policies Patient Knowledge & Attitudes Failure to promote CRC screening/ colonoscopy Missed Visits Preventive Care Missed Opportunities @Sick Visits @Well Visits Health Belief Model Framework for CRC Screening Adherence
  • 6. Trans-Theoretical Framework for CRC Screening Adherence
  • 7. Life Cycle of Human
  • 8. Health Promoting Hospitals
  • 9. Shift in in-patient demographics Age distribution of admitted patients from 1970 to 2006 Length of Stay in Hospital and Age of patients.
  • 10.
    • Primary aim: to assess the efficacy of the proposed intervention on patients’ adherence to CRC screening guideline (undergoing colonoscopy)
    • Null hypothesis: our proposed intervention will not have any impact on adherence rate.
    • Secondary aims: 1) to assess the change in patients’ perception toward CRC and CRC screening before and after the intervention (HBM). 2) to assess the change in behavioral staging of participants toward CRC screening
  • 11.
    • Preliminary Information:
    • 352 patients hospitalized in GH above age 50 surveyed.
    • 45% never had colonoscopy.
    • Of these, 70% said they will get colonoscopy if strongly recommended by physician.
    • Almost 40% prefer to have colonoscopy within 4 weeks of hospital stay.
    • 87% consider themselves as “low risk” for developing CRC.
    • Almost 65% have never looked for information on CRC.
    • 93% said “CRC could be cured if detected early”
    • Almost 70% did not worry about getting CRC.
    Study Site :
  • 12.
    • Randomized Study.
    • 195 patients in intervention group, 195 in control group.
    • Inclusion Criteria:
    • Age above 50 less than 75.
    • No prior colonoscopy within the past 10 years.
    • Exclusion Criteria:
    • Advanced dementia or cognitive impairment.
    • History of any Stage IV cancer.
    • NYHA Class IV heart failure
    • Patients on hospice care.
    • patients admitted to ICU on admission or during hospital stay.
    • Hospitalization due to gastrointestinal symptoms necessitating colonoscopy during hospitalization or as an outpatient.
    Study Design
  • 13. HBM Survey
    • 30-item questionnaire.
    • 4 dimensions: beneficence, barriers, cues to action and self efficacy.
    Total score 120 30 McQueen A ,  Tiro JA ,  Vernon SW . Construct validity and invariance of four factors associated with colorectal cancer screening across gender, race, and prior screening. Cancer Epidemiol Biomarkers Prev. 2008 Sep;17(9):2231-7 8 32 Self efficacy 4 16 Cues to action 10 40 Barriers 8 32 Beneficence Minimum score Maximum score Dimension
  • 14. TTM survey
    • Which one of these statements applies to you the most? (Only one statement)
    • I have not heard of colorectal cancer.
    • I have heard of colorectal cancer but have not heard about colorectal cancer screening.
    • I have heard of colorectal cancer screening but I do not intend to get one.
    • I have heard of colorectal cancer screening and intend to get one in near future.
  • 15.
    • Independent variable: Intervention +/-
    • Dependent variable: getting colonoscopy within 3 months. /change in HBM survey score and behavioral staging.
    • Intervening Variables: age, education, income, gender, insurance, number of co-morbidities, BMI, smoking, residency status (home vs. nursing home), marital status, race/ethnicity
    Study Design
  • 16. Patients hospitalized in Griffin Hospital Research nurse Assess eligibility Eligible patients Explain study and obtain verbal & written consent Enrolled patients Randomization allocation software Control group Intervention group HBM & TT survey Educational pamphlets from CDC regarding CRC, its risk and benefits of screening , ways of screening PROCESS ROAD MAP
  • 18. Research Flowchart Participants in intervention group Research nurse Griffin GI Department Try to schedule patients in their first preferred time Give the written instruction about timing of colonoscopy, preparation for colonoscopy for the day and night before the procedure, Direction to Griffin GI department contact numbers Obtain 3 time preferences for colonoscopy PROCESS ROAD MAP
  • 19. Intervention Group GI Department One week after scheduled date Research Nurse Colonoscopy performed ? YES Call participant HBM survey END NO Call participant HBM survey Specific reason for declining colonoscopy Participant wants 2 nd appointment ? NO TTM survey YES Contact GI department Schedule patient Repeat steps after scheduling patient PROCESS ROAD MAP
  • 20. Control group Research nurse 3 months post discharge Phone call Colonoscopy performed? YES All patients Participant answers the phone? NO Try 3 times in 2 weeks Participant answers the phone? NO YES NO HBM & TT survey Obtain contact info of Gastroenterologist who have done the procedure HBM survey Contact Gastroenterologist to verify the report END PROCESS ROAD MAP
  • 21. Statistical Analysis
    • Comparison of 2 groups:
    • - t test for continuous variables
    • - λ ² test for categorical variables
    • Outcome:
    • - t test for comparison of different proportions undergoing colonoscopy.
    • - t test for change in HBM score for pre-post intervention.
    • - t test for the comparison of HBM score changes in 2 groups.
    • - λ ² for change in TTM staging for pre-post intervention.
    • - The difference in outcomes will be adjusted based on intervening variables.
  • 22. Summary
    • Unique study.
    • Looking into the collaboration between ambulatory settings, hospitals, communities and people for health promotion.
    • If it shows the positive impact, especially community hospitals may look for other ways of promoting health in in-patient setting.
    • It boosts the current interventions for community and ambulatory clinics by adding another dimension to interventions.
  • 23.
    • THANK YOU ….