Article Figures & Data
Tables
Characteristics Physician Group Low Screeners* (n = 8) High Screeners† (n = 16) Patients in the physician's panel who are eligible for CRC screening,‡ n (range) 547 (96–928) 545 (73–944) Patients screened for CRC in 2005 (range) 42.1 (38.3–44.9) 64.8 (60.9–70.2) Physician demographics Year graduated from medical school (range) 1984 (1970–2001) 1982 (1972–1998) Men 75.0 50.0 Training and practice characteristics Years employed at Group Health, n (range) 15 (1.5–23) 17 (3–30) Panel patients by age 0–18 years 12.6 10.9 19–49 years 46.7 42.8 50–64 years 28.2 30.6 65–79 years 9.4 10.8 ≥80 years 3.1 4.9 Patients seen each week, mean n (range)§ 75 (40–95) 67 (50–100) Trained in flexible sigmoidoscopy∥ 100.0 100.0 Performed flexible sigmoidoscopy 12.5 18.8 Values provided as percentages unless otherwise indicated.
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↵* Low screeners are the physicians whose patient panels had CRC screening rates of ≤45%.
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↵† High screeners are the physicians whose patient panels had CRC screening rates of ≥60%.
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↵‡ Based on HEDIS criteria: number of patients in the physician's panel aged 50 to 80 years on December 31, 2005, and continuously enrolled in 2005 with no more than one gap in continuous enrollment of up to 45 days. Individuals with colorectal cancer and with total colectomy were excluded.
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↵§ Both part-time and full-time physicians were included as long as they had at least 50 patients eligible for CRC screening in 2005.
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↵∥ At the time of this study, most flexible sigmoidoscopy procedures were centralized at Group Health and were performed by physician assistants, nurse practitioners, or gastroenterologists.
CRC, colorectal cancer.
- Table 2. Colorectal Cancer Screening Message Recommendation of Low and High Screeners (n = 24)
Screening Message Recommendation Physician Group Total (n = 24) Illustrative Quotations Low Screeners (n = 8) High Screeners (n = 16) Colonoscopy recommended, with colonoscopy offered secondarily 4 (50.0) 7 (43.8) 11 (45.8) “Well I tell them about doing a hemoccult test first, that that's the established way and very effective way to determine whether you should have a sigmoidoscopy or colonoscopy, if result is positive. And so we talk about that—the hemoccult test that they do at home; and the fact that if it shows blood, they need to have a complete visualization of their colon. But if there's not blood, they can just do the sigmoidoscopy.…And then there are also people who want a colonoscopy…. I'm not gonna argue with someone like that.” FOBT, FS, colonoscopy all offered simultaneously and neutrally 2 (25.0) 9 (56.3) 11 (45.8) “Now, there's three different possibilities for screening. There's the sort of least, easiest, least invasive thing, but it has to be done every year, and that would be, um, doing, um, stool occult blood cards.…Um, the next option is a combination of doing the stool hemoccult. If they're positive you do a, um, colonoscopy; if they're negative then we do something called a “flexible sigmoidoscopy,' and this is actually the approach that Group Health recommends.…And then the other option is a colonoscopy, and that's the most invasive test, but it's also one that is only done every 10 years. And if it's normal, you don't have to do anything in between.” Colonoscopy recommended as first step 2 (25.0) 0 (0) 2 (8.3) “I tell patients, “if you really wanna have the best test that you can have right now—that you know is more invasive, but it's better as far as ruling in or out any disease—you should have a colonoscopy. And if it is normal then you don't need to do anything for 10 years. That is the beauty of it. Whereas if you do the other tests you have to keep repeating them. And my view of that, “cause I used to do sigmoidoscopy, is I think that's a wasted step; you might as well go straight to colonoscopy.'” Values provided as n (%).
FOBT, fecal occult blood testing; FS, flexible sigmoidoscopy.
Style Physician Group Total (n = 21) Illustrative Quotations Low Screeners (n = 7) High Screeners (n = 14) Engaged* 5 (71.4) 10 (71.4) 15 (71.4) Quote from engaged subject: “I learned a long time ago that a lot of times you can…what we now call “opportunistic care.” You know, I almost did a physical on someone that came in for elbow pain…try to click on this little screen and figure out whether their health maintenance is up…It's a little hobby on the side. All that screening and prevention is great. So the advantage is you feel like you are doing a good job. And for the patient, hopefully you catch a few patients and you do something positive. And on colon cancer you feel real good that it happened.” Nonengaged 2 (28.6) 4 (28.6) 6 (28.6) Dramatic† 1 (14.3) 10 (71.4) 11 (52.4) Quote from dramatic subject: “I had a woman who was about 56 or so who'd never had screening. And she had a sigmoidoscopy and they found a very small polyp that turned out to be cancerous. And she just had to have a short segment of her colon removed. And I said, “If she hadn't agreed to have this, by the time she'd finally been screened, it could've been too late.' So I have often used that as an example of why it's important to do it.” Nondramatic 6 (85.7) 4 (28.6) 10 (47.6) Directive‡ 5 (71.4) 3 (21.4) 8 (38.1) Quote from directive subject: “I initiate the screening discussion. Then I clarify information. Then I offer the best options for patients. And if they say, “Well, I'm not sure,' then I say, “I would recommend a flexible sigmoidoscopy.'” Nondirective 2 (28.6) 11 (78.6) 13 (61.9) Consequence messaging§ 1 (14.3) 9 (64.3) 10 (47.6) Quote using consequence messaging: “It's really pretty important. It's as good as mammography, or better, in a sense that if you catch this illness early, you're gonna get it cured….And it grows very slowly. And so, if you catch it early, you're definitely gonna be saved a miserable death. And we're all gonna go some time. But going with cancer's no good.” No consequence messaging 6 (85.7) 5 (35.7) 11 (52.4) Problem solver∥ 2 (28.6) 10 (71.4) 12 (57.1) Quote from problem solver: “The hardest part is the prep….So I usually tell my patients “Get a little Kool-Aid packet. Get the lemon one and sprinkle it on the top and chug-a-lug and it's not so bad.'” Nonproblem solver 5 (71.4) 4 (28.6) 9 (42.9) Values provided as n (%).
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↵* Engaged/nonengaged describe the enthusiasm the physician expressed for his/her beliefs about colorectal cancer (CRC) screening.
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↵† Dramatic/nondramatic describe the type of descriptive language and patient stories that the physician reported using when discussing CRC screening with patients.
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↵‡ Directive/nondirective describe the level of clarity the physician demonstrated in determining the agenda or providing information, advice, or recommendations about CRC screening.
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↵§ Consequence messaging indicates that the physician warns the patient of the risk of death, disability, or surgery as a result of CRC.
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↵∥ Problem solvers discuss a solution to identified barriers to CRC screening.
- Table 4. Barriers to and Facilitators of Colorectal Cancer (CRC) Screening and CRC Screening Message Delivery
Physician Group Total (n = 21) Low Screeners (n = 7) High Screeners (n = 14) Facilitators Mentioned per interview, mean n (range) 2.6 (2–3) 5.0 (2–7) 4.2 (2–7) Mentioned by at least half of physicians EMR EMR
Clinic staff assistance
Patient has question about any GI or prevention topic
Scheduling preventive visits
Patient has information from public or familial source about CRC
Barriers Mentioned per interview, mean n (range) 4.1 (3–6) 5.2 (2–8) 4.8 (2–8) Mentioned by at least half of physicians Test discomfort/pain
Difficult to track incomplete screening
Too little appointment time
Reluctant patients
Test discomfort and pain
Difficult to track incomplete screening
Too little appointment time
Inconvenient for patient
Test preparation difficult
Patient has too many problems to take care of at visit
Lack of EMR pop-up reminder
High cost of screening
Total facilitators and barriers per interview, mean n (range) 6.7 (5–8) 10.2 (4–14) 9.0 (4–14) EMR, electronic medical record; GI, gastrointestinal.
