Factors Associated With Clinician Recommendations for Colorectal Cancer Screening Among Average-Risk Patients: Data From a National Survey

Xuan Zhu

doi:10.5888/pcd19.210315

Factors Associated With Clinician Recommendations for Colorectal Cancer Screening Among Average-Risk Patients: Data From a National Survey

ORIGINAL RESEARCH — Volume 19 — April 14, 2022

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This flowchart shows that 3,837 clinicians were invited to participate in the study, including 3,299 primary care clinicians and 538 gastroenterologists. After 993 clinicians completed the survey, 19 clinicians were excluded because they did not indicate board certification in internal medicine, family medicine, or gastroenterology: 2 in cardiology, 1 in emergency medicine, 3 in endocrinology, 1 in forensic medicine, 1 in infectious diseases, 2 in oncology, 1 in obstetrics/gynecology, 1 in ophthalmology, 2 in pediatrics, 1 in radiology, 1 in sports medicine, and 3 with no specialty indicated. One internal medicine clinician was excluded because this clinician indicated not recommending colorectal cancer screening to average-risk patients.

Figure 1.
Selection of participants in survey on factors associated with clinician recommendations for colorectal cancer screening among average-risk patients, November–December 2019.

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Figure 2.
Factors associated with clinicians routinely recommending any of 3 of the stool-based colorectal cancer screening (CRC) methods to average-risk patients. Familiarity was measured with “Please rate your level of familiarity with the following CRC screening methods on a scale from 1 to 5, where 1 is not at all familiar and 5 is very familiar.” Perceived effectiveness was measured with “Please rate how effective the following screening methods are at reducing CRC mortality among patients who are at average risk for CRC and age 50 or older” on a 5-point scale, where 1 is not at all effective and 5 is very effective. Medicare coverage knowledge was measured with “To the best of your knowledge, does Medicare cover the following CRC screening options for asymptomatic, average-risk patients age 50 years and older with no out-of-pocket costs to patients?” Response options were yes, no, and don’t know. We combined data on Black and Hispanic clinicians because of small sample sizes. P values were adjusted using Benjamini–Hochberg procedure. Abbreviations: gFOBT, guaiac-based fecal occult blood test; FIT, fecal immunochemical test; mt-sDNA, multitarget stool DNA; ref, reference.

Factors associated with clinicians routinely recommending any of 3 of the stool-based colorectal cancer screening (CRC) methods to average-risk patients. Familiarity was measured with “Please rate your level of familiarity with the following CRC screening methods on a scale from 1 to 5, where 1 is not at all familiar and 5 is very familiar.” Perceived effectiveness was measured with “Please rate how effective the following screening methods are at reducing CRC mortality among patients who are at average risk for CRC and age 50 or older” on a 5-point scale, where 1 is not at all effective and 5 is very effective. Medicare coverage knowledge was measured with “To the best of your knowledge, does Medicare cover the following CRC screening options for asymptomatic, average-risk patients age 50 years and older with no out-of-pocket costs to patients?” Response options were yes, no, and don’t know. We combined data on Black and Hispanic clinicians because of small sample sizes. P values were adjusted using Benjamini–Hochberg procedure. Abbreviations: gFOBT, guaiac-based fecal occult blood test; FIT, fecal immunochemical test; mt-sDNA, multitarget stool DNA; ref, reference.
Variable	Odd ratio (95% CI)
Variable	gFOBT	FIT	mt-sDNA
Familiarity with this method	1.1 (0.86–1.4)	2.11 (1.71–2.62)^a	2.55 (2.04–3.23)^a
Perceived effectiveness of this method	2.42 (1.92–3.1)^a	1.75 (1.39–2.22)^a	1.8 (1.4–2.31)^a
Medicare coverage knowledge	2.37 (1.52–3.69)^a	1.62 (1.06–2.47)^a	2.05 (1.35–3.14)^a
Practice capacity
Inadequate capacity	1 [Reference]	1 [Reference]	1 [Reference]
Just about right capacity to meet demand	0.72 (0.26–1.75)	0.66 (0.29–1.4)	0.69 (0.29–1.54)
More than enough capacity to meet demand	0.56 (0.21–1.32)	0.62 (0.27–1.32)	0.79 (0.33–1.79)
Clinical specialty
Primary care clinicians	1 [Reference]	1 [Reference]	1 [Reference]
Gastroenterologists	0.44 (0.27–0.72)^a	0.44 (0.27–0.75)^a	0.45 (0.26–0.78)^a
Age in years	1.00 (0.96–1.05)	1.03 (0.98–1.07)	1.01 (0.96–1.06)
Sex
Female	0.51 (0.33–0.77)^a	0.98 (0.63–1.52)	0.87 (0.55–1.38)
Male	1 [Reference]	1 [Reference]	1 [Reference]
Race or ethnicity
Non-Hispanic White	1 [Reference]	1 [Reference]	1 [Reference]
Asian or Pacific Islander	0.85 (0.53–1.4)	0.88 (0.55–1.42)	1.3 (0.8–2.15)
Black or Hispanic	0.68 (0.31–1.61)	1.02 (0.42–2.81)	1 (0.43–2.54)
Other races	1.45 (0.6–3.91)	1.24 (0.55–3.06)	1.5 (0.63–3.93)
Years of practice after residency	0.96 (0.91–1.01)	0.94 (0.89–0.99)	0.95 (0.9–1.01)
Number of patients seen on a typical day	1.03 (1.01–1.06)^a	1.01 (0.99–1.04)	1.02 (1–1.05)
Number of providers in practice
1–5	1 [Reference]	1 [Reference]	1 [Reference]
6–15	0.88 (0.55–1.42)	1.22 (0.77–1.95)	1.45 (0.88–2.42)
≥16	0.85 (0.52–1.39)	0.88 (0.55–1.42)	0.78 (0.48–1.28)
Location of practice
Urban	1 [Reference]	1 [Reference]	1 [Reference]
Suburban	0.9 (0.58–1.41)	0.81 (0.52–1.24)	0.84 (0.53–1.31)
Rural	0.44 (0.24–0.82)^a	0.87 (0.46–1.71)	0.95 (0.47–2.01)

^a P < .05.

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Figure 3.
Factors associated with clinicians routinely recommending each visualization-based colorectal cancer screening (CRC) method to average-risk patients. Analysis on colonoscopy was omitted because only 1% of primary care physicians did not recommend colonoscopy for CRC screening; thus, we found no variability in this outcome. Familiarity was measured with “Please rate your level of familiarity with the following CRC screening methods on a scale from 1 to 5, where 1 is not at all familiar and 5 is very familiar.” Perceived effectiveness was measured with “Please rate how effective the following screening methods are at reducing CRC mortality among patients who are at average risk for CRC and age 50 or older” on a 5-point scale, where 1 is not at all effective and 5 is very effective. Medicare coverage knowledge was measured with “To the best of your knowledge, does Medicare cover the following CRC screening options for asymptomatic, average-risk patients age 50 years and older with no out-of-pocket costs to patients?” Response options were yes, no, and don’t know. We combined data on Black and Hispanic clinicians because of small sample sizes. P values were adjusted using Benjamini–Hochberg procedure. Abbreviations: CT, computed tomography; FIT, fecal immunochemical test; ref, reference.

Factors associated with clinicians routinely recommending each visualization-based colorectal cancer screening (CRC) method to average-risk patients. Analysis on colonoscopy was omitted because only 1% of primary care physicians did not recommend colonoscopy for CRC screening; thus, we found no variability in this outcome. Familiarity was measured with “Please rate your level of familiarity with the following CRC screening methods on a scale from 1 to 5, where 1 is not at all familiar and 5 is very familiar.” Perceived effectiveness was measured with “Please rate how effective the following screening methods are at reducing CRC mortality among patients who are at average risk for CRC and age 50 or older” on a 5-point scale, where 1 is not at all effective and 5 is very effective. Medicare coverage knowledge was measured with “To the best of your knowledge, does Medicare cover the following CRC screening options for asymptomatic, average-risk patients age 50 years and older with no out-of-pocket costs to patients?” Response options were yes, no, and don’t know. We combined data on Black and Hispanic clinicians because of small sample sizes. P values were adjusted using Benjamini–Hochberg procedure. Abbreviations: CT, computed tomography; FIT, fecal immunochemical test; ref, reference
Variable	Odds ratio (95% CI)
Variable	CT colonography	Flexible sigmoidoscopy	Flexible sigmoidoscopy with FIT
Familiarity with this method	1.31 (1.11–1.56)^a	1.25 (1.02–1.54)	1.54 (1.27–1.89)^a
Perceived effectiveness of this method	1.74 (1.43–2.14)^a	3.05 (2.51–3.73)^a	2.01 (1.63–2.49)^a
Medicare coverage knowledge	2.08 (1.41–3.06)^a	1.05 (0.75–1.48)	1.43 (1.01–2.02)^a
Practice capacity
Inadequate capacity	1 [Reference]	1 [Reference]	1 [Reference]
Just about right capacity to meet demand	1.04 (0.67–1.63)	1.58 (0.97–2.61)	2.15 (1.27–3.75)^a
More than enough capacity to meet demand	1.15 (0.71–1.88)	1.56 (0.93–2.65)	1.99 (1.14–3.56)^a
Clinical specialty
Primary care clinicians	1 [Reference]	1 [Reference]	1 [Reference]
Gastroenterologists	1.24 (0.80–1.92)	0.78 (0.49–1.25)	0.76 (0.48–1.21)
Age in years	0.99 (0.95–1.02)	1.02 (0.98–1.05)	1.06 (1.02–1.1)^a
Sex
Female	1.12 (0.76–1.64)	1.02 (0.70–1.48)	0.97 (0.65–1.43)
Male	1 [Reference]	1 [Reference]	1 [Reference]
Race or ethnicity
Non-Hispanic White	1 [Reference]	1 [Reference]	1 [Reference]
Asian or Pacific Islander	1.58 (1.07–2.32)^a	1.05 (0.71–1.54)	1.45 (0.98–2.15)
Black or Hispanic	0.65 (0.30–1.34)	0.37 (0.16–0.79)	1 (0.47–2.05)
Other races	1.34 (0.66–2.67)	1.73 (0.87–3.43)	2.61 (1.29–5.29)^a
Years of practice after residency	0.98 (0.94–1.02)	0.95 (0.91–0.99)	0.91 (0.87–0.95)^a
Number of patients seen on a typical day	0.99 (0.98–1.01)	1.02 (1–1.04)	1.02 (1.01–1.04)^a
Number of providers in practice
1–5	1 [Reference]	1 [Reference]	1 [Reference]
6–15	2.12 (1.40–3.21)^a	1.64 (1.10–2.46)^a	1.43 (0.95–2.16)
≥16	2.26 (1.49–3.45)^a	1.91 (1.26–2.89)^a	1.4 (0.92–2.12)
Location of practice
Urban	1 [Reference]	1 [Reference]	1 [Reference]
Suburban	1.03 (0.72–1.49)	0.87 (0.61–1.24)	1.05 (0.73–1.51)
Rural	1.41 (0.78–2.51)	0.87 (0.48–1.56)	1.07 (0.57–1.95)

^a P < .05.

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