Colonoscopy fears overcome when patients support patients

Jan 8 2008

Patients who have had a colonoscopy can play a life-saving role by encouraging other patients to follow through with their own colorectal cancer screenings, according to new research from the University of Pennsylvania School of Medicine.

These peer coaches can provide important information to combat myths and fears that serve as barriers to colonoscopy – issues patients say their doctors often fail to address. In a randomized trial, clinicians in the Division of General Internal Medicine studied patients who were at increased risk of missing their scheduled colon study appointment. They found that those who received telephone mentoring from a trained “peer coach” were two times more likely to keep their first colonoscopy appointment than those who received an educational brochure about the procedure in the mail or received no peer or literature support.

“This study addresses an important gap in colorectal cancer prevention in the United States – patients who don't follow through with their appointments,” says lead author Barbara J. Turner, MD, MSEd, Professor of Medicine and Director of Penn's General Medicine Physician Scientist Fellowship. “This is one of the first studies to show that patients can help other patients overcome barriers to getting tests that can prevent this deadly disease.” The findings will be published this month in the Journal of General Internal Medicine.

Colorectal cancer is the second most common cause of cancer-related death in the United States, but less than 60 percent of Americans over the age of 50 have had a screening colonoscopy or sigmoidoscopy in the past ten years. Even when patients schedule appointments for these tests, one-third of patients cancel, in part because they have unanswered questions or unfounded fears about the procedure or the colon-cleansing preparation.

Turner and her colleague Kevin Fosnocht, MD, Penn Presbyterian Chief Quality and Patient Safety Officer, ran a training program for the five peer coaches, each of whom had previously had a colonoscopy. During the program, the coaches learned about communication strategies, the biology of colorectal cancer, screening modalities and potential barriers to colonoscopy. The coaches then called study patients within two weeks of their appointment to offer education and encouragement by following a scripted guide. Patients in the brochure group received pamphlets from the American Cancer Society and the U.S. Centers for Disease Control and Prevention.

Study patients were mostly female and black, and compared with other patient groups, patients randomized to the peer coach support group were more likely to be Medicaid insured and have low primary care visit adherence. Among those who received the telephone peer counseling, nearly 70 percent kept their colonoscopy appointment. Turner and colleagues estimated that without peer support, only 52 percent of patients with similar characteristics would have attended their appointment. Only 58 percent of those who received the brochure attended their appointment, while only 48 percent patients who refused any study support attended.

During follow-up phone calls, 80 percent of patients in the peer coach arm of the study rated their coaching as “very helpful,” and most appreciated hearing about another patient's experience and commented on their need for more information than was provided by their physician.

Those findings mirror previous Penn research, published in the August 2007 issue of the Journal of Family Practice, which identified communications shortfalls among doctors discussing colonoscopy with patients. Although most doctors studied explained the value of screening to patients, few touched on issues concerning insurance coverage for the procedure – a barrier for many patients – dietary issues before the procedure, or risks of the procedure. Some doctors used colloquial terms that could be regarded as crude – “It's basically Liquid Plumber for your bowels,” for instance, when explaining the prep for the procedure – or too technical for patients to understand. Still others provided information that was simply incorrect.