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Research ArticleOriginal Research

Why Hasn't This Patient Been Screened for Colon Cancer? An Iowa Research Network Study

Barcey T. Levy, Terri Nordin, Suzanne Sinift, Marcy Rosenbaum and Paul A. James
The Journal of the American Board of Family Medicine September 2007, 20 (5) 458-468; DOI: https://doi.org/10.3122/jabfm.2007.05.070058
Barcey T. Levy
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Terri Nordin
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Suzanne Sinift
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Marcy Rosenbaum
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Paul A. James
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Abstract

Background: Less than half of eligible Americans have been screened for colorectal cancer (CRC). The objective of this study was to describe physicians’ reasons for screening or not screening specific patients for CRC and their approach to CRC testing discussions.

Methods: This study used mixed-methods. Physicians described their reasons for screening or not screening 6 randomly chosen patients who were eligible for CRC screening (3 screened and 3 not screened) whose CRC testing status was ascertained by medical record review. Verbatim transcripts from physicians responding to structured interview questions were used to identify themes. Specific elements of discussion were examined for their association with each physician's screening rate. Fifteen randomly chosen Iowa family physicians from the Iowa Research Network stratified by privileges to perform colonoscopy, flexible sigmoidoscopy, or neither procedure dictated the reasons why 43 patients were screened and 40 patients were not screened.

Results: Reasons patients were not up to date fell into 2 major categories: (1) no discussion by physician (50%) and (2) patient refusal (43%). Reasons for no discussion included lack of opportunity, assessment that cost would be prohibitive, distraction by other life issues/health problems, physician forgetfulness, and expected patient refusal. Patients declined because of cost, lack of interest, autonomy, other life issues, fear of screening, and lack of symptoms. Patients who were up to date received (1) diagnostic testing (for previous colon pathology or symptoms; 56%) or (2) asymptomatic screening (44%). Physicians who were more adamant about screening had higher screening rates (P < .05; Wilcoxon rank sum). Physicians framed their recommendations differently (“I recommend” vs “They recommend”), with lower screening rates among physicians who used “they recommend” (P = .05; Wilcoxon rank sum).

Conclusions: Reasons many patients remain unscreened for CRC include (1) factors related to the health care system, patient, and physician that impede or prevent discussion; (2) patient refusal; and (3) the focus on diagnostic testing. Strategies to improve screening might include patient and physician education about the rationale for screening, universal coverage for health maintenance exams, and development of effective tracking and reminder systems. The words physicians choose to frame their recommendations are important and should be explored further.

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The Journal of the American Board of Family Medicine: 20 (5)
The Journal of the American Board of Family Medicine
Vol. 20, Issue 5
September-October 2007
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Why Hasn't This Patient Been Screened for Colon Cancer? An Iowa Research Network Study
Barcey T. Levy, Terri Nordin, Suzanne Sinift, Marcy Rosenbaum, Paul A. James
The Journal of the American Board of Family Medicine Sep 2007, 20 (5) 458-468; DOI: 10.3122/jabfm.2007.05.070058

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Why Hasn't This Patient Been Screened for Colon Cancer? An Iowa Research Network Study
Barcey T. Levy, Terri Nordin, Suzanne Sinift, Marcy Rosenbaum, Paul A. James
The Journal of the American Board of Family Medicine Sep 2007, 20 (5) 458-468; DOI: 10.3122/jabfm.2007.05.070058
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  • A Randomized Controlled Trial to Improve Colon Cancer Screening in Rural Family Medicine: An Iowa Research Network (IRENE) Study
  • Mailed Fecal Immunochemical Tests Plus Educational Materials to Improve Colon Cancer Screening Rates in Iowa Research Network (IRENE) Practices
  • A Randomized Colorectal Cancer Screening Intervention Trial in the Iowa Research Network (IRENE): Study Recruitment Methods and Baseline Results
  • Influence of Primary Care Use on Population Delivery of Colorectal Cancer Screening
  • Asia Pacific consensus recommendations for colorectal cancer screening
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