Patient clock drawing and accuracy of self-report compared with chart review for colorectal cancer (CRC) screening

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Abstract

The purpose of this study was to test the accuracy of patient colorectal cancer (CRC) screening self-report and CRC screening documented in their medical record for those who are cognitively impaired and those who are not based on the clock drawing task. A cross-sectional study where patient survey and medical record information were linked was conducted in 16 primary care offices. Of the 960 patients mailed questionnaires, there were 493 respondents who completed the questionnaire and clock drawing, had a chart review, and had no help in drawing the clock or completing the questionnaire. Chart review was conducted for CRC screening in physician offices. Clock drawings were scored 0–7 according to the Watson method. Accuracy of ever being screened for CRC or being up-to-date for CRC screening was determined by comparing self-report with medical records and calculating sensitivity, specificity, positive and negative predictive values, false positive rate, and false negative rate. Seventy-five clocks were abnormal, scoring 4 or more. Agreement between self-reported colonoscopy and medical record review was higher in subjects with normal clock drawings than those with abnormal clock drawings. When examining predictors of agreement/disagreement for colonoscopy screening, abnormal clock drawing was the single predictor for higher disagreement.

Introduction

Accuracy, freedom from a mistake or error, for self-reporting colorectal cancer (CRC) screening has been found to be inconsistent (Levy et al., 2006). Persons who self-report may have cognitive impairment and possibly make errors in reporting. A potential means to alleviate this inconsistency is to determine a respondent's cognitive abilities at the time of self-report. Conducting a cognitive screen, such as the clock drawing task, offers the potential for eliminating incorrect self-reports from persons who are cognitively impaired.

Many screening tests exist for measurement of cognitive function: Blessed Test of Orientation, Concentration, and Memory (Blessed et al., 1968), Dementia Rating Scale (Kay, 1977), Mini-Mental State Examination (Folstein et al., 1975), Short Portable Mental Status Questionnaire (Pfeiffer, 1975), Wechsler Memory Scale (Wechsler, 1945), and Visual Counting Test (Fishback, 1977). These tests take time to administer and need to be completed in an environment conducive to concentration on the task at hand. A simple cognitive function test is the clock drawing task which is quick to complete. The person is asked to draw the face of a clock inside a pre-drawn circle or from scratch, mark in the numbers and then draw the hands to indicate a specified time. The clock drawing task can be used to screen for cognitive impairment, dementia, and as a measure of spatial dysfunction and neglect.

Compared to the above-mentioned tests, the clock drawing task is non-threatening, requires minimal equipment, usable in multiple languages and cultures, and can be administered to the hearing impaired (Brodaty and Moore, 1997). The Watson et al. (1993) method for a scoring the clock drawings has high sensitivity (87%) and specificity (82%) for identifying dementia and is simple to score (Agrell and Dehlin, 1998). The clock drawing task correlates well with other well-established cognitive screens, such as the MMSE (Shulman et al., 1986, Shulman, 2000), the Dementia Rating Scale, Global Deterioration Scale, Blessed Dementia Rating Scale, and the Short Portable Mental Status Questionnaire (Sunderland et al., 1989, Mendez et al., 1992).

The purpose of this study is to test the accuracy of patient CRC screening self-report and CRC screening documented in their medical record for those who are cognitively impaired and those who are not based on the clock drawing task.

Section snippets

Design

The data for this study are derived from a cross-sectional survey of CRC screening whose purpose was to examine patient and physician factors associated with documented CRC testing according to national guidelines. The final section of the mailed questionnaire included a clock drawing task to test cognitive abilities. Typical memory tests have to have a presenter and receiver present to register the results. The clock drawing allowed for paper completion without a presenter in attendance.

Participants

Two

Results

Of the 960 patients who were mailed the questionnaire, returns were received from 572 patients (60%) and detailed chart reviews were completed on 511 (53% of the original sample) charts. Eighteen respondents reported they had help completing the clock drawing of which 12 reported someone drew the entire clock for them, 4 reported someone filled the numbers in on the clock for them, and the remaining 2 reported having some help with the questionnaire. The sample for this study is the 493

Discussion

The clock drawing test requires a diverse range of higher level cognitive abilities (Freedman et al., 1994). Persons have to have language skills, verbal understanding, memory, spatially coded knowledge, and constructive skills to perform the task (Critchley, 1953, Agrell and Dehlin, 1998, Paganini-Hill et al., 2001). It is a simple test that takes relatively little time, crosses cultural boundaries and can be completed by all ages except the very young. An epidemiological study demonstrated

Conclusions

Agreement between self-reported colonoscopy and medical record review was higher in subjects with normal clock drawings than those with abnormal clock drawings. Accuracy measures for self-reported colonoscopy were higher in the normal clock drawing group compared to the abnormal drawing group. Fewer than half of the respondents were up-to-date with the CRC screening and 15% had an abnormal clock drawing. Recommendations are to include a clock drawing in mailed surveys to persons who are older

Conflict of interest statement

None.

Acknowledgements

Financial support was provided by the University of Iowa Department of Family Medicine and Agency for Healthcare Research and Quality (grants R21 HS014490 and R21 HS013581).

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