Work

A Pilot Study to Examine Colorectal Cancer Screening in Two Assisted Living Communities

Year: 2014

Type: article

Abstract: Colorectal cancer (CRC) is a leading cause of cancer death.1 Current guidelines for CRC screening recommend universal screening for adults aged 50 to 75.1 From age 76 to 85, screening decisions should be based on health status and personal values. After age 85, screening is not recommended given lack of benefit.1, 2 Studies of adults living independently and in nursing homes have shown inappropriate CRC screening (over- and underuse) in all age ranges.3-5 Whether CRC screening rates for individuals in assisted living (AL) communities—who are less impaired than those in nursing homes—are inappropriate is unknown. To explore CRC screening in AL, interviews and chart review of a cross-sectional sample were conducted in two AL communities in central North Carolina. This study included residents aged 50 to 90 recruited during summer 2012 who had no history of colon cancer or irritable bowel disease. Consent was obtained from residents or, for those with dementia, their family members. The study consisted of an interview with the resident or a family member and a review of the resident's AL site and primary care provider (PCP) chart. Subjects provided basic demographic and health information. Residents were placed into one of three health status categories using the Charlson Comorbidity Index (CCI) modified for age, as used in prior work examining the appropriateness of CRC screening.6 Additional information included the resident's CRC screening history and the most-recent results of any colonoscopy, fecal occult blood test (FOBT), or sigmoidoscopy. CRC screening rates were compared between health status categories using the Cochran-Armitage chi-square test for trend using SAS version 9.2 (SAS Institute, Inc., Cary, NC) and Stata/SE, version 10.0 (StataCorp, College Station, TX). Of 153 eligible residents, 93 (61%) participated (62% by family proxy). Based on modified CCI, 24 (26%) residents were in good health, 13 (14%) in intermediate health, and 56 (60%) in poor health. The mean age of the residents and family members was 79.2 and 58.2, respectively. Most residents were female (69%) and racially and educationally diverse (45% black, 39% some college). As shown in Figure 1A, 30 residents (32%) had never undergone CRC screening. There was no association between health status and having ever been screened (P = .63). Sixteen residents (17%) had had a colonoscopy, 17(18%) a FOBT, 20 (22%) both, and 10 (11%) another combination. Twenty-eight (30%) were up to date with CRC screening (Figure 1B), with those in good health significantly more likely to be up to date (P = .01), although 21% of those in poor health were up to date with screening. Most who were up to date had had a colonoscopy in the past 10 years (15/27). The two AL communities did not differ significantly in the number of residents who had ever been screened (64% vs 71%, P = .66) but differed in the number of residents up to date with screening (19% vs 39%, P = .04) and health status (74% vs 37% in poor health, P = .002). In this pilot study, approximately half of the AL residents were no longer receiving CRC screening, and only 29% were up to date with screening, suggesting opportunities for improvement. Screening rates for the healthiest older adults (50%) were similar to rates in non-AL community-dwelling adults reported elsewhere,3 providing evidence of underscreening. Contrary to research in other populations,7, 8 significant differences were found in screening according to health, such that healthier individuals were more likely to be up to date with screening, although 20% of those unlikely to benefit and in poor health continued to be screened, providing evidence of overscreening. Its small sample size limited this study, and its findings are not generalizable, although sites with diverse populations were purposefully chosen to increase variability, and problems with appropriate screening were found at both sites. Other than possible regional variability, it seems likely that inappropriate rates of being up to date with screening are typical of this population. Further work should examine CRC screening rates and other preventive services on a larger scale in AL communities to confirm the generalizability of these findings and explore the reasons for the over- and underuse of screening. This manuscript was presented as a poster at the John B. Graham Student Research Day at the University of North Carolina at Chapel Hill School of Medicine on January 17, 2013, and on May 3–4, 2013, at the American Geriatrics Society annual conference at the Presidential poster session and student poster session. Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper. Dr. Kistler was supported by Award K12 HS19468–01 from the Agency for Healthcare Research and Quality awarded to the University of North Carolina (UNC) Mentored Career Development Program in Comparative Effectiveness Research and by the UNC Lineberger Comprehensive Cancer Center. This research also was supported by the National Center for Research Resources and the National Center for Advancing Translational Sciences, National Institutes of Health, through Grant KL2TR000084. It was conducted as one of the Collaborative Studies in Long-Term Care through the Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill. Author Contributions: Kathryn Moore and Christine Kistler had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Kistler, Lewis, Zimmerman. Acquisition of data: Moore, Ward, Rodriguez, Kistler. Analysis and interpretation of data: Moore, Lewis, Zimmerman, Reed, Kistler. Drafting of the manuscript: Moore, Lewis, Zimmerman, Kistler. Critical revision of the manuscript for important intellectual content: Moore, Lewis, Zimmerman, Reed, Ward, Rodriguez, Kistler. Statistical analysis: Reed, Kistler. Obtained funding: Moore, Kistler. Administrative, technical, and material support: Ward. Sponsor's Role: The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Source: Journal of the American Geriatrics Society

DOI: 10.1111/jgs.12665