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Effect of a Mailed Brochure on Appointment-Keeping for Screening Colonoscopy: A Randomized Trial

Thomas D. Denberg, MD, PhD; John M. Coombes, MD; Tim E. Byers, MD, MPH; Alfred C. Marcus, PhD; Lawrence E. Feinberg, MD; John F. Steiner, MD, MPH; and Dennis J. Ahnen, MD
[+] Article, Author, and Disclosure Information

From University of Colorado at Denver and Health Sciences Center, Denver, Colorado.

Acknowledgments: The authors thank Brenda L. Beaty, MPH, for statistical analysis and Trisha V. Melhado, BS, for data collection.

Grant Support: In part by the American Cancer Society MRSG-06-081-01-CPPB; Principal Investigator, Dr. Denberg.

Potential Financial Conflicts of Interest: None disclosed.

Requests for Single Reprints: Thomas Denberg, MD, PhD, 4200 E. 9th Avenue, B-180, Division of General Internal Medicine, University of Colorado at Denver and Health Sciences Center, Denver, CO 80262; e-mail, tom.denberg@uchsc.edu.

Current Author Addresses: Dr. Denberg: 4200 East 9th Avenue, B-180, Division of General Internal Medicine, University of Colorado at Denver and Health Sciences Center, Denver, CO 80262.

Dr. Coombes: 4200 East 9th Avenue, B-158, Division of Gastroenterology and Hepatology, University of Colorado at Denver and Health Sciences Center, Denver, CO 80262.

Dr. Byers: Campus Box F-519, Department of Preventive Medicine and Biometrics, University of Colorado at Denver and Health Sciences Center, Aurora, CO 80045.

Dr. Marcus: Campus Box B-119, Department of Preventive Medicine and Biometrics, University of Colorado at Denver and Health Sciences Center, Denver, CO 80262.

Dr. Feinberg: Campus Box B-212, 360 South Garfield Street, Suite 520, Division of General Internal Medicine, University of Colorado at Denver and Health Sciences Center, Denver, CO 80209.

Dr. Steiner: Campus Box F-443, Colorado Health Outcomes Program, University of Colorado at Denver and Health Sciences Center, Aurora, CO 80045.

Dr. Ahnen: Denver Veterans Affairs Medical Center, Department of Gastroenterology and Hepatology, 1055 Clermont Street, Denver, CO 80220.

Author Contributions: Conception and design: T.D. Denberg, J.M. Coombes, D.J. Ahnen.

Analysis and interpretation of the data: T.D. Denberg, J.M. Coombes, T.E. Byers, A.C. Marcus, D.J. Ahnen.

Drafting of the article: T.D. Denberg, J.M. Coombes, A.C. Marcus.

Critical revision of the article for important intellectual content: T.D. Denberg, J.M. Coombes, T.E. Byers, J.F. Steiner, L.E. Feinberg, D.J. Ahnen.

Final approval of the article: T.D. Denberg, T.E. Byers, A.C. Marcus, L.E. Feinberg, D.J. Ahnen.

Provision of study materials or patients: L.E. Feinberg.

Obtaining of funding: T.D. Denberg.

Administrative, technical, or logistic support: T.D. Denberg.

Collection and assembly of data: J.M. Coombes.

Ann Intern Med. 2006;145(12):895-900. doi:10.7326/0003-4819-145-12-200612190-00006
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As of 2004, almost 45% of adults age 50 years or older were not up-to-date with colorectal cancer (CRC) screening (1). In community settings, a key barrier to screening is the absence of a primary care physician recommending screening (2). Nonetheless, previous work has demonstrated that adherence is low even when patients have face-to-face discussions with and receive referrals for screening from their primary care physicians (3). This observation is particularly true for colonoscopy, a high-intensity procedure that requires considerable advance preparation. We have reported in our clinical system the reasons for not adhering to colonoscopy referrals, including the belief that one is not at risk for CRC because of an absence of symptoms or a family history of disease, fear of pain associated with the procedure, perceived unpleasantness of the bowel preparation, forgetfulness, and uncertainty about who is responsible for scheduling the procedure (3). Nonadherence to referrals for coloscopy represents a missed opportunity to realize public health goals and achieve quality of care for individual patients and also entails unnecessary administrative time and expense to complete, transmit, and archive referral forms and obtain insurance preauthorization.



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Distribution of Patient Brochures: A pragmatic solution to resolving the information gap
Posted on March 1, 2007
Pascal Vignally
Laboratoire Sante publique, Faculte de Medecine, Marseille, France
Conflict of Interest: None Declared

The study of Denberg el al illustrates the problems of providing patients with information to improve adherence with routine but invasive examinations such as colonoscopy. This procedure is often prescribed by a general practitioner (GP) but conducted by a specialist. The GP may not have the time or skills to provide the patient with necessary information about the procedure or its potential benefits and risks, while the specialist usually sees the patient for the first time on the day that the procedure is to be performed. As a result, the information that the patient receives is often unclear or incomplete. The legal obligation of providing clear and complete information to patients has led to the development of new approaches in fields such as anesthesiology (1,2). We evaluated the effects of applying one such approach on patient knowledge and satisfaction with colonoscopy. In our study, we randomized 34 patients who had been referred for colonoscopy, drawn from the practices of 11 GPs, into 2 groups. The first received a brochure from their GP that had been developed by the French gastroenterology society; they also had access to special consultation with a member of the colonoscopy team if they desired. The second received routine information. Knowledge of benefits and risks and satisfaction with the care they had received were evaluated via patient interview 2 days after the procedure. The group receiving the brochure, 20% of whom also took advantage of the special consultation service, had higher knowledge levels compared to the routine information group 5.2 ± 2.1 versus 3.3 ± 2.1 (p<0.04) on a 8 points scale, as well as a higher level of satisfaction with the medical care, 24.9 ± 4.6 versus 23.0 ± 5.1 (p<0.03) on a 30 points scale. This study demonstrated that knowledge levels were low in those who did not receive the brochure and did not have access to consultation, and that such an intervention increased both knowledge and patient satisfaction. In the context of increasing litigation between patients and practitioners such lack of knowledge may be highly damaging for practitioners (3). Indeed, Neale's study demonstrated that 33% of litigations for colonoscopy were linked with misinformation, especially concerning possible complications (4). Although providing optional consultation with members of the specialist team may not be feasible in all settings, the distribution by GPs of patient brochures developed by specialists may be a pragmatic solution to resolving the information gap. If patients receive the brochure far enough in advance of the procedure, they would presumably have time to assimilate the information, and those wishing further clarification would be able to seek answers from specialists in the field.

1.Loi n° 2002-303 du 4 mars 2002 relative aux droits des malades et à la qualité du système de santé. JO n° 54. p 4118

2.Grimaud JC. Proof of information delivered to patients. Gastroenterol Clin Biol. 2003 Jan; 27(1):15-6

3.Studdert DM, Mello MM, Gawande AA et al. Claims, errors, and compensation payments in medical malpractice litigation. N Engl J Med. 2006 May 11;354(19):2024-33

4.Neale G. Reducing risks in gastroenterological practice. Gut 1998; 42: 139-42

Conflict of Interest:

None declared

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