Direct observation of counseling on colorectal cancer in rural primary care practices

Barriers to screening colonoscopy in an urban population: a study to help focus further efforts to attain full compliance

BACKGROUND

Awareness of colorectal cancer and decision for colorectal cancer screening is influenced by multiple factors including ethnicity, level of education, and adherence to regular medical follow up.

OBJECTIVE

Our survey aimed at assessing barriers to colorectal cancer screening among urban population.

DESIGN

This study is a survey of the general population.

SETTING

This study was made at a local community in the downtown area of a metropolitan city.

PATIENTS/SUBJECTS

The study population for this survey included 2000 non-institutionalized residents from local community of Brooklyn downtown area of City of Brooklyn, NY, USA. All participants were 50 years or older.

INTERVENTION

No intervention was done.

MAIN OUTCOME MEASUREMENT

The survey questionnaire collected information about demographic, socioeconomic level, awareness of various cancers and their screening methods, and awareness of screening colonoscopy.

RESULTS

Colonoscopy was identified as the best screening test by 31 % of the subjects. Pain and discomfort was the major reason for not having a colonoscopy. The fear of a complication declined significantly after the first colonoscopy but fear of pain and discomfort increased. Difficulty with bowel preparation before a colonoscopy was a significant problem; it discouraged significant number of participants from having another colonoscopy.

LIMITATION

This study is limited by its small sample size.

CONCLUSION

Physician/family and peer influence seems important but influencing only a minority of subjects. Fear of complications should be allayed using accurate statistical information. Pain should be significantly diminished and/or eliminated during colonoscopy. Future research should focus to minimize complexity and discomfort associated with bowel preparation.

Contrasts in rural and urban barriers to colorectal cancer screening

OBJECTIVES

To contrast barriers to colon cancer (CRC) screening and Fecal Occult Blood Test (FOBT) completion between rural and urban safety-net patients.

METHODS

Interviews were administered to 972 patients who were not up-to-date with screening.

RESULTS

Rural patients were more likely to believe it was helpful to find CRC early (89.7% vs 66.1%, p < .0001), yet were less likely to have received a screening recommendation (36.4% vs. 45.8%, p = .03) or FOBT information (14.5% vs 32.3%, p < .0001) or to have completed an FOBT (22.0% vs 45.8%, p < .0001).

CONCLUSIONS

Interventions are needed to increase screening recommendation, education and completion, particularly in rural areas.

Individual- and provider-level factors associated with colorectal cancer screening in accordance with guideline recommendation: a community-level perspective across varying levels of risk

BACKGROUND

Participation rates in colorectal cancer screening (CRC) are low. Relatively little is known about screening uptake across varying levels of risk and across population groups. The purpose of the current study was to identify factors associated with (i) ever receiving colorectal cancer (CRC) testing; (ii) risk-appropriate CRC screening in accordance with guidelines; and (iii) recent colonoscopy screening.

METHODS

1592 at-risk persons (aged 56-88 years) were randomly selected from the Hunter Community Study (HCS), Australia. Participants self-reported family history of CRC was used to quantify risk in accordance with national screening guidelines.

RESULTS

1117 participants returned a questionnaire; 760 respondents were eligible for screening and analysis. Ever receiving CRC testing was significantly more likely for persons: aged 65-74 years; who had discussed with a doctor their family history of CRC or had ever received screening advice. For respondents "at or slightly above average risk", guideline-appropriate screening was significantly more likely for persons: aged 65-74 years; with higher household income; and who had ever received screening advice. For respondents at "moderately or potentially high risk", guideline-appropriate screening was significantly more likely for persons: with private health insurance and who had discussed their family history of CRC with a doctor. Colonoscopy screening was significantly more likely for persons: who had ever smoked; discussed their family history of CRC with a doctor; or had ever received screening advice.

CONCLUSIONS

The level of risk-appropriate screening varied across populations groups. Interventions that target population groups less likely to engage in CRC screening are pivotal for decreasing screening inequalities.

American Indian perceptions of colorectal cancer screening: viewpoints from adults under age 50

Colorectal cancer (CRC) mortality rates have decreased in the general US population; however, CRC mortality rates are increasing among American Indians (AI). AI CRC screening rates remain low when compared to other ethnic groups. Our team investigated CRC screening education prior to recommended age for screening to better understand screening perceptions among AI community members. Our research team conducted 11 focus groups with AI men and women aged 30-49 (N = 39 men and N = 31 women) in Kansas and Missouri. The results revealed that community members (1) have little knowledge of CRC, (2) do not openly discuss CRC, and (3) want additional CRC education. Variations existed among men and women's groups, but they agreed that preventive measures need to be appropriate for AI communities. Thus, AI CRC screening interventions should be culturally tailored to better meet the needs of the population.

Primary care physicians' prevention counseling with patients with multiple morbidity

The prevalence of multiple health conditions, or multiple morbidity (MM), is increasing. Providing medical care for adults with MM presents challenges, including balancing disease management with prevention. We conducted in-depth semistructured interviews with 12 primary care physicians to explore their perspectives on prevention counseling among patients with MM. Participants described the complex relationship between disease management and prevention, highlighted the importance of patient motivation, and discussed various strategies to promote receptivity to prevention recommendations. The perceived potential benefits of prevention recommendations encouraged physicians to persist with such counseling, despite challenges presented by visit time constraints, reimbursement procedures, and concerns over futility. Physicians recommended the development of alternate care delivery and reimbursement models to overcome challenges of the existing health care system and to meet the prevention needs of patients with MM. We explore the implications of these findings for maximizing the health and quality of life of adults with MM.

Colon cancer screening in women

Colorectal cancer is the third leading cause of cancer-related deaths in women. Colorectal cancer is a preventable disease with accepted screening modalities that have been proven to save lives. As women are more likely than men to develop right-sided colon cancers, colonoscopy is the preferred screening test in women. Currently, women are less likely to undergo colorectal cancer screening than men. Frank discussions addressing the fear or embarrassment of endoscopic screening are important in helping women overcome these barriers. Enhanced education of both practitioners and patients targeted to improve colorectal cancer screening adherence will improve early diagnosis and patient survival.

Colorectal cancer risk assessment and screening recommendation: a community survey of healthcare providers' practice from a patient perspective

Background

Family history is a common risk factor for colorectal cancer (CRC), yet it is often underused to guide risk assessment and the provision of risk-appropriate CRC screening recommendation. The aim of this study was to identify from a patient perspective health care providers' current practice relating to: (i) assessment of family history of CRC; (ii) notification of "increased risk" to patients at "moderately/potentially high" familial risk; and (iii) recommendation that patients undertake CRC screening.

Methods

1592 persons aged 56-88 years randomly selected from the Hunter Community Study (HCS), New South Wales, Australia were mailed a questionnaire. 1117 participants (70%) returned a questionnaire.

Results

Thirty eight percent of respondents reported ever being asked about their family history of CRC. Ever discussing family history of CRC with a health care provider was significantly more likely to occur for persons with a higher level of education, who had ever received screening advice and with a lower physical component summary score. Fifty one percent of persons at "moderately/potentially high risk" were notified of their "increased risk" of developing CRC. Thirty one percent of persons across each level of risk had ever received CRC screening advice from a health care provider. Screening advice provision was significantly more likely to occur for persons who had ever discussed their family history of CRC with a health care provider and who were at "moderately/potentially high risk".

Conclusions

Effective interventions that integrate both the assessment and notification of familial risk of CRC to the wider population are needed. Systematic and cost-effective mechanisms that facilitate family history collection, risk assessment and provision of screening advice within the primary health care setting are required.

Methodological diversity and integration in health communication inquiry

Research on health communication is complicated by myriad individual, organizational, and societal factors that influence health-related decisions and behaviors, making it difficult to control for secular trends (uncontrolled social and environmental influences) that affect health care and health promotion practices. Sophisticated research on health communication must take into account the numerous situational, psychological, and societal factors to fully examine the often hidden dynamics of health care and health promotion. This essay examines major research challenges, strategies, and opportunities for making sense of the complexities of health communication processes, recommending the power of methodological diversity and integration for health research.

Colorectal cancer screening practices of primary care physicians in Washington State

BACKGROUND

Colorectal cancer screening reduces death from colorectal cancer, but screening rates are low. While research has identified barriers to screening from the patient perspective, less research has addressed screening from the physician perspective.

METHODS

The Washington Comprehensive Cancer Control Partnership conducted a survey of primary care physicians in Washington State to measure their knowledge, attitudes, and practices for colorectal cancer screening of average-risk patients. The survey was mailed to a simple random sample of 700 primary care physicians in Washington State. Sixty-nine percent of the eligible physicians in the sample participated.

RESULTS

Most respondents (76%) recommended one or more colorectal cancer screening tests in agreement with American Cancer Society guidelines, and 93% perceived patient anxiety about colorectal cancer screening tests to be a significant barrier to screening. Ninety percent of physicians reported using the fecal occult blood test (FOBT) as a screening test, but most did not report performing any tracking or using any mechanism to encourage their patients to complete and return FOBT kits.

CONCLUSIONS

These findings suggest three intervention approaches to increase colorectal cancer screening in primary care settings: improve physicians' knowledge about current screening guidelines (especially appropriate age and screening intervals), encourage physicians to strongly recommend screening to patients, and help physicians adopt tracking systems to follow screening to completion.

Perceived medical discrimination and cancer screening behaviors of racial and ethnic minority adults

BACKGROUND

Discrimination has been shown as a major causal factor in health disparities, yet little is known about the relationship between perceived medical discrimination (versus general discrimination outside of medical settings) and cancer screening behaviors. We examined whether perceived medical discrimination is associated with lower screening rates for colorectal and breast cancers among racial and ethnic minority adult Californians.

METHODS

Pooled cross-sectional data from 2003 and 2005 California Health Interview Survey were examined for cancer screening trends among African American, American Indian/Alaskan Native, Asian, and Latino adult respondents reporting perceived medical discrimination compared with those not reporting discrimination (n = 11,245). Outcome measures were dichotomous screening variables for colorectal cancer among respondents ages 50 to 75 years and breast cancer among women ages 40 to 75 years.

RESULTS

Women perceiving medical discrimination were less likely to be screened for colorectal [odds ratio (OR), 0.66; 95% confidence interval (95% CI), 0.64-0.69] or breast cancer (OR, 0.52; 95% CI, 0.51-0.54) compared with women not perceiving discrimination. Although men who perceived medical discrimination were no less likely to be screened for colorectal cancer than those who did not (OR, 1.02; 95% CI, 0.97-1.07), significantly lower screening rates were found among men who perceived discrimination and reported having a usual source of health care (OR, 0.30; 95% CI, 0.28-0.32).

CONCLUSIONS

These findings of a significant association between perceived racial or ethnic-based medical discrimination and cancer screening behaviors have serious implications for cancer health disparities. Gender differences in patterns for screening and perceived medical discrimination warrant further investigation.

Discussing weight with obese primary care patients: physician and patient perceptions

OBJECTIVE

To evaluate patient-provider agreement on whether weight and related behaviors were discussed during routine visits.

DESIGN

Post-visit survey assessments of patients and providers.

PARTICIPANTS

Obese patients make up the majority of all patients seen in primary care (PC). The patients and physicians were recruited at the time of PC visits.

MEASUREMENTS AND MAIN RESULTS

Percent patient-physician agreement and patient, provider and practice characteristics associated with agreement. Patients (456) and physicians (30) agreed about whether or not they discussed weight, physical activity (PA), and diet for 61% of office visits. There was disagreement on one of the items (weight, PA, or diet) for 23% of office visits, and for 2 or more of the items for 16% of the visits. Agreement was relatively greater for discussing weight than for discussing diet or physical activity. Physicians reported discussing weight issues more often than did patients. Overall patient-physician agreement was 0.51-0.59 (weighted Kappa statistic). In a multivariate analyses of factors associated with patient-physician agreement, health insurance (odds ratio [OR]=3.67, p value = 0.002), physician description of patient weight status (OR = 2.27, p value = 0.002), patient report of how weight relates to health (OR = 1.70, p value = 0.04), and female patient gender (OR = 1.62, p = value = 0.02) were significantly related to agreement.

CONCLUSIONS

Patients and providers disagreed about whether or not weight issues were discussed in a large number of primary care encounters in this study. Physicians may be able to improve care for their obese patients by focusing discussions on specific details of diet and physical activity behaviors, and by clarifying that patients perceive weight-related information has been shared.

Barriers of and facilitators to physician recommendation of colorectal cancer screening

BACKGROUND

Colorectal cancer screening (CRCS) has been demonstrated to be effective and is consistently recommended by clinical practice guidelines. However, only slightly over half of all Americans have ever been screened. Patients cite physician recommendation as the most important motivator of screening. This study explored the barriers of and facilitators to physician recommendation of CRCS.

METHODS

A 3-component qualitative study to explore the barriers of and facilitators to physician recommendation of CRCS: in-depth, semistructured interviews with 29 purposively sampled, community- and academic-based primary care physicians; chart-stimulated recall, a technique that utilizes patient charts to probe physician recall and provide context about the barriers of and facilitators to physician recommendation of CRCS during actual clinic encounters; and focus groups with 18 academic primary care physicians. Grounded theory techniques of analysis were used.

RESULTS

All the participating physicians were aware of and recommended CRCS. The overwhelmingly preferred test was colonoscopy. Barriers of physician recommendation of CRCS included patient comorbidities, prior patient refusal of screening, physician forgetfulness, acute care visits, lack of time, and lack of reminder systems and test tracking systems. Facilitators to physician recommendation of CRCS included patient request, patient age 50-59, physician positive attitudes about CRCS, physician prioritization of screening, visits devoted to preventive health, reminders, and incentives.

CONCLUSION

There are multiple physician, patient, and system barriers to recommending CRCS. Thus, interventions may need to target barriers at multiple levels to successfully increase physician recommendation of CRCS.

Physician and staff perceptions of barriers to colorectal cancer screening in Appalachian Kentucky

BACKGROUND

Data indicate that in 1997 to 1999, only 44% of Appalachian Kentuckians underwent colorectal cancer screening consistent with guidelines. We investigated the reasons for, barriers to, and follow-up of colorectal cancer (CRC) screening recommendations in primary care practices seeing patients from Appalachian Kentucky.

METHODS

A mixed-methods [qualitative (focus group) and quantitative (survey)] approach was used to gather and analyze data in five primary care practices. A total of 34 participated in the focus groups.

RESULTS

In focus groups, physicians and office staff reported a number of indicators for CRC screening; physician, patient, and procedural barriers to CRC screening; and strategies to overcome these barriers to screening. Most physicians used personal experience to guide screening, but it was unclear what was meant by personal experience. Commonly cited patient barriers to screening were fear and embarrassment. Physicians reported several approaches to overcome these barriers, including establishing trust and educating patients. Survey data identified a number of resources to assist practices in promoting screening, most commonly, patient educational materials. Finally, fecal occult blood test was most commonly recommended because it is inexpensive and easy to administer.

CONCLUSIONS

Our mixed methods approach not only helped to understand the physicians' perceptions of the problems and barriers to CRC screening in Appalachian Kentucky, but also elucidated how practices endeavor to overcome these barriers and identified the additional resources practices would like in order to promote CRC screening.

Physician colorectal cancer screening recommendations: an examination based on informed decision making

OBJECTIVE

The purpose of this research was to examine the content of physicians' colorectal cancer screening recommendations. More specifically, using the framework of informed decision making synthesized by Braddock and colleagues, we conducted a qualitative study of the content of recommendations to describe how physicians are currently presenting this information to patients.

METHODS

We conducted semi-structured interviews with 65 primary care physicians. We analyzed responses to a question designed to elicit how the physicians typically communicate their recommendation.

RESULTS

Almost all of the physicians (98.5%) addressed the "nature of decision" element. A majority of physicians discussed "uncertainties associated with the decision" (67.7%). Fewer physicians covered "the patient's role in decision making" (33.8%), "risks and benefits" (16.9%), "alternatives" (10.8%), "assessment of patient understanding" (6.2%), or "exploration of patient's preferences" (1.5%).

CONCLUSION

We propose that the content of the colorectal screening recommendation is a critical determinant to whether a patient undergoes screening. Our examination of physician recommendations yielded mixed results, and the deficiencies identified opportunities for improvement.

PRACTICE IMPLICATIONS

We suggest primary care physicians clarify that screening is meant for those who are asymptotic, present tangible and intangible benefits and risks, as well as make a primary recommendation, and, if needed, a "compromise" recommendation, in order to increase screening utilization.

Colorectal cancer testing among patients cared for by Iowa family physicians

BACKGROUND

Colorectal cancer (CRC) can be largely prevented or effectively treated, yet about half of eligible Americans have not been screened. The purpose of this study was to examine patient and physician factors associated with documented CRC testing according to national guidelines.

METHODS

Cross-sectional study where 511 randomly selected rural patients aged 55 to 80 years of 16 board-certified Iowa family physicians were enrolled in 2004. Patient survey and medical record information were linked with physician surveys. Predictors of CRC testing were examined using a regression procedure that accommodated random physician effects (2005-2006).

RESULTS

Forty-six percent of patients were up-to-date with CRC testing in accordance with national guidelines. This percentage varied from 5% to 75% by physician (p < 0.0001). Of the patients who were up-to-date, 89% had colonoscopy, and 62% had symptoms prior to testing that could indicate CRC. The strongest univariate predictors other than symptoms were patient recollection of physician recommendation (odds ratio [OR] = 6.4, 95% confidence interval [CI] = 4.2-9.6) and physician documentation of recommendation (OR = 14.1, CI = 8.5-23.3). A multivariable regression model showed testing in accordance with guidelines significantly increased with government insurance (OR = 1.6, CI = 1.2-2.3), having a health maintenance visit in the preceding 26 months (OR = 2.4, CI = 1.4-4.1), family history of CRC (OR = 3.1, CI = 1.6-5.8), number of medical conditions (OR = 1.2 for each additional condition, CI = 1.1-1.3), high importance of screening to patient (OR = 2.6, CI = 1.5-4.5), patient satisfaction with doctor's discussions (OR = 3.3, CI = 2.2-4.8), physician trained in flexible sigmoidoscopy (OR = 2.3, CI = 1.6-3.4), and physician report of trying to follow American Cancer Society (ACS) guidelines (OR = 1.7, CI = 1.2-2.5). After excluding patients who had symptoms prior to screening, most of the ORs in the logistic regression analysis increased except that the number of medical conditions and physician trying to follow ACS guidelines became nonsignificant.

CONCLUSIONS

Fewer than half of rural patients received CRC testing, and most of those tested had symptoms. Physician recommendations and the manner of presenting the recommendations greatly influenced whether patients were tested.

Colorectal carcinoma screening procedure use among primary care patients

BACKGROUND

Despite evidence-based recommendations for colorectal carcinoma screening, population-based surveys report low screening rates. To the authors' knowledge, the extent to which screening procedures are used by patients seen in primary care is not as clear. The authors estimated the annual and 5-year colorectal carcinoma screening procedure use among a cohort of primary care patients and evaluated the correlation between patient characteristics and the use of screening procedures.

METHODS

The authors identified a cohort of patients (n = 21,833 patients) ages 55-70 years who had a primary care visit in 2003 and who were enrolled in a health plan for the 5-year period ending December 31, 2003. Using automated data for the 5-year period ending December 31, 2003, information on patient sociodemographic characteristics, primary care and health maintenance examination (HME) visits, comorbid diagnoses, income, and screening receipt was compiled. The latter included barium enema, colonoscopy, fecal occult blood testing (FOBT), and flexible sigmoidoscopy use.

RESULTS

Approximately one-half of insured, primary care patients (54%) received recommended colorectal carcinoma screening procedures over the 5-year observation period. Among individuals who received screening, colonoscopy was used most frequently (39.9%), followed by flexible sigmoidoscopy testing alone (28.3%) or in combination with FOBT (4.3%). Annual screening rates increased by 3.1% between 1999 and 2003. Among individuals who did not receive recommended colorectal carcinoma screening, 64% had at least 3 HME visits, and 41% received at least 1 FOBT. Increasing HME visits and other primary care visit frequency, along with increasing age, income, male gender, and African-American race, were associated with screening receipt.

CONCLUSIONS

Significant opportunities exist to increase colorectal carcinoma screening among primary care patients.

Barriers to colorectal cancer screening: a comparison of reports from primary care physicians and average-risk adults

BACKGROUND

Barriers to colorectal cancer (CRC) screening are not well understood.

OBJECTIVES

We sought to compare barriers to CRC screening reported by primary care physicians (PCPs) and by average-risk adults, and to examine characteristics of average-risk adults who identified lack of provider recommendation as a major barrier to CRC screening.

RESEARCH DESIGN

This was a comparative study using data from the 1999-2000 Survey of Colorectal Cancer Screening Practices and the 2000 National Health Interview Survey (NHIS).

SUBJECTS

We recruited nationally representative samples of PCPs (n= 1235) from the SCCSP and average-risk adults (n = 6497) from the NHIS.

MEASURES

We measured barriers to CRC screening identified by PCPs and average-risk adults who were not current with screening.

RESULTS

Both PCPs and average-risk adults identified lack of patient awareness and physician recommendation as key barriers to obtaining CRC screening. PCPs also frequently cited patient embarrassment/anxiety about testing and test cost/lack of insurance coverage, but few adults identified these as major barriers. Of adults not current with testing, those who had visited a doctor in the past year or had health insurance were more likely to report lack of physician recommendation as the main reason they were not up-to-date compared with their counterparts with no doctor visit or health insurance. Only 10% of adults not current with testing and who had a doctor visit in the past year reported receiving a screening recommendation.

CONCLUSIONS

A need exists for continued efforts to educate the public about CRC and the important role of screening in preventing this disease. Practice-based strategies to systematically prompt health care providers to discuss CRC screening with eligible patients also are required.

Differences in preventive health quality by residency year. Is seniority better?

BACKGROUND

It is assumed that the performance of more senior residents is superior to that of interns, but this has not been assessed objectively.

OBJECTIVE

To determine whether adherence to national guidelines for outpatient preventive health services differs by year of residency training.

DESIGN

Cross-sectional study.

PARTICIPANTS

One hundred twenty Internal Medicine residents, postgraduate year (PGY)- 1 and PGY -2, attending a University Internal Medicine teaching clinic between June 2000 and May 2003.

MEASUREMENTS

We studied 6 preventive health care services offered or received by patients by abstracting data from 1,017 patient records. We examined the differences in performance between PGY-1 and PGY-2 residents.

RESULTS

Postgraduate year-2 residents did not statistically outperform PGY-1 residents on any measure. The overall proportion of patients receiving appropriate preventive health services for pneumococcal vaccination, advising tobacco cessation, breast and colon cancer screening, and lipid screening was similar across levels of training. PGY-1s outperformed PGY-2s for tobacco use screening (58%, 51%, P = .03). These results were consistent after accounting for clustering of patients within provider and adjusting for patient age, gender, race and insurance, resident gender, and number of visits during the measurement year.

CONCLUSIONS

Overall, patients cared for by PGY-2 residents did not receive more outpatient preventive health services than those cared for by PGY-1 residents. Efforts should be made to ensure quality patient care in the outpatient setting for all levels of training.

Colorectal cancer screening among African American church members: a qualitative and quantitative study of patient-provider communication

Background

A healthcare provider's recommendation to undergo screening has been shown to be one of the strongest predictors of completing a colorectal cancer (CRC) screening test. We sought to determine the relationship between the general quality of self-rated patient-provider communication and the completion of CRC screening.

Methods

A formative study using qualitative data from focus groups and quantitative data from a cross-sectional survey of church members about the quality of their communication with their healthcare provider, their CRC risk knowledge, and whether they had completed CRC screening tests. Focus group participants were a convenience sample of African American church members. Participants for the survey were recruited by telephone from membership lists of 12 African American churches located in rural counties of North Carolina to participate in the WATCH (Wellness for African Americans Through Churches) Project.

Results

Focus Groups. Six focus groups (n = 45) were conducted prior to the baseline survey. Discussions focused on CRC knowledge, and perceived barriers/motivators to CRC screening. A theme that emerged during each groups' discussion about CRC screening was the quality of the participants' communication with their health care provider. Survey. Among the 397 participants over age 50, 31% reported CRC screening within the recommended guidelines. Participants who self-rated their communication as good were more likely to have been screened (36%) within the recommended guidelines than were participants with poor communication (17%) (OR = 2.8, 95% CI 1.2, 6.4; p = 0.013). Participants who had adequate CRC knowledge completed CRC screening at a higher rate than those with inadequate knowledge (p = 0.011). The percentage of participants with CRC screening in the recommended guidelines, stratified by communication and knowledge group were: 42% for good communication/adequate knowledge; 27% for good communication/inadequate knowledge; 29% for poor communication/adequate knowledge; and 5% for poor communication/inadequate knowledge.

Conclusions

Participants who rated their patient-provider communication as good were more likely to have completed CRC screening tests than those reporting poor communication. Among participants reporting good communication, knowledge about colorectal cancer was also associated with test completion. Interventions to improve patient-provider communication may be important to increase low rates of CRC screening test completion among African Americans.

Association of socioeconomic status and receipt of colorectal cancer investigations: a population-based retrospective cohort study

BACKGROUND

Although the Canadian health care system was designed to ensure equal access, inequities persist. It is not known if inequities exist for receipt of investigations used to screen for colorectal cancer (CRC). We examined the association between socioeconomic status and receipt of colorectal investigation in Ontario.

METHODS

People aged 50 to 70 years living in Ontario on Jan. 1, 1997, who did not have a history of CRC, inflammatory bowel disease or colorectal investigation within the previous 5 years were followed until death or Dec. 31, 2001. Receipt of any colorectal investigation between 1997 and 2001 inclusive was determined by means of linked administrative databases. Income was imputed as the mean household income of the person's census enumeration area. Multivariate analysis was performed to evaluate the relationship between the receipt of any colorectal investigation and income.

RESULTS

Of the study cohort of 1,664,188 people, 21.2% received a colorectal investigation in 1997-2001. Multivariate analysis demonstrated a significant association between receipt of any colorectal investigation and income (p < 0.001); people in the highest-income quintile had higher odds of receiving any colorectal investigation (adjusted odds ratio [OR] 1.38; 95% confidence interval [CI] 1.36-1.40) and of receiving colonoscopy (adjusted OR 1.50; 95% CI 1.48-1.53).

INTERPRETATION

Socioeconomic status is associated with receipt of colorectal investigations in Ontario. Only one-fifth of people in the screening-eligible age group received any colorectal investigation. Further work is needed to determine the reason for this low rate and to explore whether it affects CRC mortality.

Barriers to colorectal cancer screening in rural primary care

BACKGROUND

Residents of rural communities may face unique barriers to obtaining colorectal cancer (CRC) screening, including reduced access to services. This study assessed the impact of patient, physician, and practice characteristics on rural primary care patient receipt of CRC screening.

METHODS

We surveyed patients (N = 801) over 50 years of age and primary care physicians (N = 36) in rural practices. Medical students administered surveys to assess patient demographics, self-reported CRC screening, practice features, local availability of endoscopy, and physician screening test preferences. We used multivariable logistic regression analyses to investigate associations between independent variables, and (1) patient CRC screening status and (2) adequacy of CRC discussions between physicians and patients.

RESULTS

Fifty-seven percent of patients reported being up-to-date with colorectal cancer screening and most in this group had received FOBT and endoscopy. A minority of patients (39%) reported adequate time to discuss CRC screening, and this was positively associated with being up-to-date with CRC screening in a multivariable analysis. Endoscopy was available in 58% of the practices and 44% of the practices had local gastroenterologists available on at least a monthly basis. The availability of endoscopic procedures and gastroenterological services were not associated with CRC screening or with use of endoscopy as a screening method.

CONCLUSIONS

CRC screening among rural primary care patients is related to adequacy of physician CRC screening discussions but not access to endoscopic procedures. Efforts to improve CRC screening should focus on improving physician-patient discussions of CRC.

Colorectal cancer screening: clinical applications

Screening for colorectal cancer reduces mortality in individuals aged 50 years or older. A number of screening tests, including fecal occult blood tests, sigmoidoscopy, double-contrast barium enema, and colonoscopy, are recommended by professional organizations for colorectal cancer screening, yet the rates of colorectal cancer screening remain low. Questions regarding the quality of evidence for each screening test, whether screening for individuals at higher risk should be modified, the availability of the tests, and cost-effectiveness are addressed. Many potential barriers to colorectal cancer screening exist for the patient and the physician. Strategies to increase compliance for colorectal cancer screening are proposed.