A single question may be useful for detecting patients with inadequate health literacy in a VA population.

Background The Veterans Health Administration, the American Cancer Society, and the American Geriatrics Society recommend colorectal cancer screening for older adults unless they are unlikely to live 5 years or have significant comorbidity that would preclude treatment. Objective To determine whether colorectal cancer screening is targeted to healthy older patients and is avoided in older patients with severe comorbidity who have life expectancies < 5 years. Design Cohort study. Setting Minneapolis, Durham, Portland, and West LA VA’s with linked national VA and Medicare administrative claims. Patients 27,068 patients > 70 years who had an outpatient visit in 2000 and an outpatient visit at 1 of 4 VA’s during 2001–2002 and due for screening. Measurements The main outcome was receipt of fecal occult blood testing (FOBT), colonoscopy, sigmoidoscopy, or barium enema during 2001–2002 based on national VA and Medicare claims. Charlson comorbidity scores were used to stratify patients into 3 groups ranging from no comorbidity (score=0) to severe comorbidity (score > 4) and 5-year mortality was determined for each group. Results 46% of patients were screened during 2001–2002. Only 47% of patients with no comorbidity were screened despite having life expectancies > 5 years (5-year mortality=19%). While the incidence of screening declined with age and worsening comorbidity, it was still 41% for patients with severe comorbidity who had life expectancies < 5 years (5-year mortality=55%). The number of VA outpatient visits predicted screening independent of comorbidity, such that patients with severe comorbidity and > 4 visits had similar or higher screening rates than healthier patients with fewer visits. Limitations Some tests may have been performed for non-screening reasons. The generalizability of findings to persons who do not use the VA is uncertain. Conclusions Advancing age was inversely associated with colorectal cancer screening while comorbidity was a weaker predictor. More attention to comorbidity is needed to better target screening to older patients with substantial life expectancies and avoid screening older patients with limited life expectancies.

Mailed interventions enhance patient knowledge and self-reported participation in decision making, and alter screening preferences. The pamphlet and video interventions evaluated are comparable in effectiveness. The lower-cost pamphlet approach is an attractive option for clinics with limited resources.

Context Several prior studies have found that women are less likely to be screened for colorectal cancer (CRC) than men. While the source of this screening differential is unknown, recent studies suggest gender differences in barriers to screening might explain the disparity.Objective This formative study was designed to explore CRC screening barriers, attitudes and preferences by gender.Methodology Focus group interviews with groups stratified by gender and screening status. Participants included 27 females and 43 males between the ages of 50 and 75 years who receive primary care at the Minneapolis VA Medical Center. We conducted interpretive and grounded text analysis of semi-structured focus group interviews to assess how knowledge, experiences and sociocultural norms shape female and male preferences and barriers to current CRC screening guidelines.Results Female and male participants reported similar preferences for CRC screening mode, but there were notable differences in the barriers and facilitators to screening. Key findings suggest that women viewed the preparation for endoscopic procedures as a major barrier to screening while men did not; women and men expressed different fears and information preferences regarding endoscopic procedures; and women perceive CRC as a male disease thus feeling less vulnerable to CRC. Gender-specific barriers may explain women's lower rate of screening for CRC.Conclusion Colorectal cancer screening promotion interventions, decision aids and clinical practice may benefit by being tailored by gender.

Objective: The aim of the study was to validate selfreported colorectal cancer (CRC) screening using the National Cancer Institute Colorectal Cancer Screening questionnaire. Materials and Methods: 890 patients, ages 50 to 75 years, from the Minneapolis Veterans Affairs (VA) Medical Center were surveyed by mail. Phone administration was attempted with mail nonresponders. VA and non-VA records were combined for the reference standard. Sensitivity, specificity, concordance, and report-torecords ratio (R2R) were estimated for overall and test-specific CRC adherence among respondents providing complete medical records. Secondary analyses examined variation in estimates by patient characteristics, treatment of missing and uncertain responses, and whether a strict or liberal time interval was used for assessing concordance. Results: Complete medical records were available for 345 of the 686 survey responders. For overall adherence, sensitivity was 0.98, specificity was 0.59, concordance was 0.88, and R2R was 1.14. Sensitivity was 0.82 for fecal occult blood test (FOBT), 0.75 for sigmoidoscopy, 0.97 for colonoscopy, and 0.63 for double-contrast barium enema (DCBE). Specificity was 0.89 for FOBT, 0.76 for sigmoidoscopy, 0.72 for colonoscopy, and 0.85 for DCBE. Concordance was >0.80 for all tests other than sigmoidoscopy (0.76). R2R was 1.31 for FOBT, 1.33 for sigmoidoscopy, 1.42 for colonoscopy, and 6.13 for DCBE. The R2R was lower for a combined sigmoidoscopy and colonoscopy measure. Overreporting was more pronounced for older, less-educated individuals with no family history of CRC. Sensitivity and R2R improved using a liberal interval and treating uncertain responses as nonadherent (versus missing), but differences were not statistically significant. Conclusions: Self-reported CRC screening validity is generally acceptable and robust across definitional decisions, but varies by screening test and patient characteristics. (Cancer Epidemiol Biomarkers Prev 2008;17(4):768 -76)

A B S T R A C TObjectives. We examined the extent to which experiences of racial discrimination are associated with bodily pain reported by African American men.Methods. The study sample consisted of 393 African American male veterans who responded to a national survey of patients aged 50-75 who received care from the Veterans Health Administration (VHA). Veterans were surveyed by mail, with a telephone follow-up. The response rate for African Americans in the sample was 60.5%. Pain (assessed using the bodily pain subscale of the 36-item short-form health survey), experiences of discrimination, employment, education, and income were obtained through the survey. Age, race, and mental health comorbidities were obtained from VA administrative data. Multiple regression analysis adjusting for item non-response (via imputation) and unit non-response (via propensity scores and weighting) was used to assess the association between racial discrimination and likelihood of experiencing moderate or severe pain over the past 4 weeks.Results. Experiences of racial discrimination were associated with greater bodily pain (b = -0.25, P < 0.0001), even after controlling for socioeconomic and health-related characteristics.Conclusion. Perceived racial discrimination was associated with greater pain among a sample of older African American male patients in the VA. Additional research is needed to replicate this finding among other populations of African Americans.

Facility-level strategies undertaken to implement national PM systems may result in inappropriate clinical care, can distract providers from patient concerns, and may have a negative effect on patient education and autonomy. Further research is needed to ascertain how features of centralized PM systems influence whether measures are translated locally by facilities into more or less patient-centered policies and processes.

Background It is unclear whether lack of follow-up after screening FOBT in older adults is due to screening patients whose comorbidity or preferences do not permit follow-up versus failure to complete follow-up in healthy patients. Methods Prospective cohort study of 2,410 patients ≥ 70 years screened with FOBT at 4 VA’s between 1/1/01-12/31/01. Main outcome was receipt of follow-up within 1 year of FOBT based on national VA and Medicare data. For patients with positive FOBT results, age and Charlson comorbidity scores were evaluated as potential predictors of receiving complete colon evaluation (colonoscopy or sigmoidoscopy plus barium enema) and medical records were reviewed to determine reasons for lack of follow-up. Results 212 (9%) patients had positive FOBT results; 42% received complete colon evaluation within 1 year. Age and comorbidity were not associated with receipt of complete follow-up, which was similar among patients 70–74 years with Charlson=0 compared with patients ≥ 80 years with Charlson≥1 (48% vs 41%; P=0.28). VA site, number of positive FOBT cards, and number of VA outpatient visits were predictors. Of 122 patients who did not receive follow-up within 1 year, 38% had documentation that comorbidity or preferences did not permit follow-up, and over the next 5 years 76% never received follow-up. Conclusions While follow-up after positive FOBT results was low regardless of age or comorbidity, screening patients in whom complete evaluation would not be pursued substantially contributes to lack of follow-up. Efforts to improve follow-up should address the full chain of decision-making, including decisions to screen and decisions to follow-up.