Primary care variability in patients at higher risk for colorectal cancer: evaluation of screening and preventive care practices

<p><b>Objective:</b> Sub-optimal colorectal cancer (CRC) evaluations have been attributed to both physician and patient factors. The primary objective of this study was to evaluate physician practice variation in patients with a higher risk of CRC. We wanted to identify the physician characteristics and the types of patients that were associated with missed screening opportunities; we also explored whether screening for CRC served as a proxy for better preventive care practices.</p> <p><b>Methods:</b> A total of 213 board-certified family and internal medicine physicians participated in the study, conducted between September and December 2016. We used Clinical Performance and Value (CPV^®) vignettes, simulated patients, to collect data on CRC screening. The CPV patients presented with a typical range of signs and symptoms of potential CRC. The care provided to the simulated patients was scored against explicit evidence-based criteria. The main outcome measure was rate a diagnostic CRC workup was ordered. This data quantified the clinical practice variability for CRC screening in high risk patients and other preventive and screening practices.</p> <p><b>Results:</b> A total of 81% of participants ordered appropriate CRC workup in patients at risk for CRC, with a majority (71%) selecting diagnostic colonoscopy over FIT/FOBT. Only 6% of physicians ordering CRC workup, however, counseled patients on their higher risk for CRC. The most commonly recognized symptoms prompting testing were unexplained weight loss or inadequate screening history, while the least recognized symptoms of CRC risk were abdominal discomfort found on review of systems.</p> <p><b>Conclusion:</b> This study shows that primary care physician screening of CRC varies widely. Those physicians who successfully screened for CRC were more likely to complete other prevention and screening practices.</p

Clinical Utility of a Comprehensive, Whole Genome CMA Testing Platform in Pediatrics: A Prospective Randomized Controlled Trial of Simulated Patients in Physician Practices

<div><p>Background</p><p>Developmental disorders (DD), including autism spectrum disorder (ASD) and intellectual disability (ID), are a common group of clinical manifestations caused by a variety of genetic abnormalities. Genetic testing, including chromosomal microarray (CMA), plays an important role in diagnosing these conditions, but CMA can be limited by incomplete coverage of genetic abnormalities and lack of guidance for conditions rarely seen by treating physicians.</p><p>Methods</p><p>We conducted a longitudinal, randomized controlled trial investigating the impact of a higher resolution 2.8 million (MM) probe-CMA test on the quality of care delivered by practicing general pediatricians and specialists. To overcome the twin problems of finding an adequate sample size of multiple rare conditions and under/incorrect diagnoses, we used standardized simulated patients known as CPVs. Physicians, randomized into control and intervention groups, cared for the CPV pediatric patients with DD/ASD/ID. Care responses were scored against evidence-based criteria. In round one, participants could order diagnostic tests including existing CMA tests. In round two, intervention physicians could order the 2.8MM probe-CMA test. Outcome measures included overall quality of care and quality of the diagnosis and treatment plan.</p><p>Results</p><p>Physicians ordering CMA testing had 5.43% (p<0.001) higher overall quality scores than those who did not. Intervention physicians ordering the 2.8MM probe-CMA test had 7.20% (p<0.001) higher overall quality scores. Use of the 2.8MM probe-CMA test led to a 10.9% (p<0.001) improvement in the diagnosis and treatment score. Introduction of the 2.8MM probe-CMA test led to significant improvements in condition-specific interventions including an 8.3% (p = 0.04) improvement in evaluation and therapy for gross motor delays caused by Hunter syndrome, a 27.5% (p = 0.03) increase in early cognitive intervention for FOXG1-related disorder, and an 18.2% (p<0.001) improvement in referrals to child neurology for Dravet syndrome.</p><p>Conclusion</p><p>Physician use of the 2.8MM probe-CMA test significantly improves overall quality as well as diagnosis and treatment quality for simulated cases of pediatric DD/ASD/ID patients, and delivers additional clinical utility over existing CMA tests.</p></div

Flowchart of Physician Participant Selection.

<p>(139/147 (95%) physicians in the intervention arm confirmed viewing an educational webcast about the 2.8MM probe-CMA. No physicians in the control arm received any specific educational material.</p

Characteristics of Physicians.

<p>Characteristics of Physicians.</p

Multivariate linear regression model linking CMA and Utility: Overall CPV Scores.

<p>Multivariate linear regression model linking CMA and Utility: Overall CPV Scores.</p

Proportion of Cases in Which Physician Ordered Genetic Testing by Round.

<p>Proportion of Cases in Which Physician Ordered Genetic Testing by Round.</p

Case specific diagnostic and treatment practice changes among the intervention group.

<p>Case specific diagnostic and treatment practice changes among the intervention group.</p