Regular articleA national survey of primary care physicians’ colorectal cancer screening recommendations and practices
Introduction
During the latter half of the 1990s, evidence emerging from clinical studies [1], [2], [3], [4], [5], [6], [7], [8], [9] prompted a number of expert groups [10], [11], [12] to issue or revise their recommendations for colorectal cancer (CRC) screening. With varying approaches to evaluating evidence and formulating recommendations, these groups developed guidelines that differ somewhat in the CRC screening modalities they support as well as the frequency with which recommended modalities are to be applied. Nevertheless, a consensus has emerged in recent years that average-risk adults aged 50 years and older should be screened for CRC.
Despite the evidence in support of screening for CRC and the dissemination of screening guidelines, national surveys of the public indicate that the majority of adults aged 50 and older have never been screened for this disease. For example, data from the 1998 National Health Interview Survey (NHIS), an in-person household survey of a nationally representative sample of the noninstitutionalized U.S. population, show 33% of adults aged 50 years and older to have received a fecal occult blood test (FOBT) in the 2 years before the interview and 38% to have ever undergone a proctoscopy/sigmoidoscopy examination [13]. The 1999 Behavioral Risk Factor Surveillance System (BRFSS), a population-based, random-digit-dialed telephone survey of the noninstitutionalized U.S. population, indicates that 40% of adults aged 50 years and older have ever had an FOBT and 44% a sigmoidoscopy or colonoscopy examination [14]. Trend data from these surveys demonstrate only modest improvement in CRC screening rates over time [13], [14], [15].
Health care providers play a key role in recommending screening to eligible patients. Yet nationally representative data on providers’ CRC screening knowledge, attitudes, and practices are sparse. Prior studies have been state or locally based, with small sample sizes, low response rates, a focus on opinions about guidelines rather than actual practice or, if addressing provider practices, have targeted only one or two of the four currently recognized CRC screening modalities [16], [17], [18], [19], [20], [21], [22], [23], [24], [25], [26], [27]. To address these gaps, the National Cancer Institute—in collaboration with the Centers for Disease Control and Prevention and the Centers for Medicare and Medicaid Services—fielded the Survey of Colorectal Cancer Screening Practices in Health Care Organizations. This comprehensive survey of primary care and specialty physicians and health plan medical directors is designed to obtain current, nationally representative data on how CRC screening is being conducted in the United States, and to identify barriers to screening delivery in community practice [28]. In this report, we summarize primary care physicians’ (PCPs’) beliefs about the effectiveness of CRC screening, their recommendations to patients for CRC screening, and their self-reported CRC screening activities in their clinical practices.
Section snippets
Sampling methodology
Using the American Medical Association’s Physician Masterfile as the sampling frame, we surveyed a nationally representative sample of PCPs in 1999–2000. The Masterfile contains demographic and practice-related data on all allopathic and virtually all osteopathic physicians in the United States. Eligible respondents were PCPs aged 75 years and younger who were listed in the database as having an active license to practice medicine and whose major professional activity involves patient care. We
Description of respondents
A total of 1235 practicing PCPs responded to the survey (overall response rate = 72%; GPs = 68%, FPs = 75%, IMs = 69%, OBGs = 75%). Ninety percent responded by mail, 6% by Internet, 2% by telephone, and 2% by fax. The majority were male, white, graduates of U.S. medical schools, and in group practice (Table 1). The mean age was 48.0 years (range, 29–75 years). Differences in physician and practice characteristics by specialty were apparent. For example, GPs tended to be older, to lack board
Discussion
Given the low documented rates of CRC screening among older adults in the United States, there is a critical need to understand current screening beliefs and practices from the provider perspective. This survey of PCPs’ CRC screening attitudes and practices is unique because it covers all of the CRC screening modalities (FOBT, sigmoidoscopy, colonoscopy, and DCBE) most commonly mentioned in published guidelines, and provides national estimates of CRC screening recommendations and practices for
Acknowledgements
We thank Dr. Lorayn Olson, project director for Abt Associates, Inc. (Chicago, IL), for survey research work and Timothy McNeel of Information Management Services, Inc., for data preparation assistance. Funding support for this study was provided by the National Cancer Institute (contract number N01-PC-85169) and the Centers for Disease Control and Prevention (inter-agency agreement number 99FED06571).
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