Despite the established effectiveness and cost effectiveness of CRCS and its widespread promulgation by clinical practice guidelines, CRCS rates remain suboptimal. However, studies show that most patients report they would undergo CRCS if their physician recommended it.10,12
This study identifies many specific barriers to and facilitators of physician recommendation of CRCS.
Consistent with our conceptual framework, barriers of and facilitators to physician recommendation were identified at the patient, physician, and system levels. Thus, addressing 1 barrier may not be sufficient to raise physician rates of CRCS recommendation. Multifaceted interventions are likely to be required to effectively raise CRCS rates.34–38
This study identifies several modifiable barriers and facilitators that inform the design interventions to raise the rates of physician recommendation of CRCS. On the patient level, continued patient education of CRCS is not only a means of raising awareness and acceptance among patients, but can also be a cue to action for physicians to offer CRCS. This study shows that physicians are responsive to an active request or inquiry on the part of the patient.
On the physician level, awareness and attitudes about CRCS were very favorable. Although physicians reported that they recommend CRCS, review of their medical records revealed that their rates of recommendation of CRCS were suboptimal. Of the 124 encounters that met the criteria for chart-stimulated recall, 46 had evidence that a CRCS test had been completed and another 22 received a recommendation from their physician at the index visit examined by chart-stimulated recall. Thus, only 55% of the encounters had evidence of a recommendation for screening within the interval recommended by clinical practice guidelines. One potential intervention to raise physician CRCS recommendation rates would be to provide physicians with awareness of their own rates of CRCS to overcome the misperception that all their patients have received a recommendation for CRCS. Anecdotally, several participating physicians reported that this study had been an intervention by making them aware of the cases where screening should have been recommended and was not.
Another physician barrier is their response to a patient who had previously refused CRCS. Physicians may not offer screening again to patients that have previously refused screening. However, behavioral theory suggests behavioral changes occur in stages. The transtheoretical model supports that stage of readiness to change occurs in small steps along a continuum that ultimately leads in a behavioral change.39
One study of stage of adoption of CRCS found that 56% of low-income and African-American women are in the precontemplation stage of adoption where they knew very little and have not yet actively thought about CRCS.40
Our findings support the need for further physician education of stage-based communication theory.
The most frequently cited physician barrier is forgetfulness. Clearly, systems that build physician reminders, either electronic or paper,41,42
related to preventive care and counseling are needed to assist physicians in systematically recommending CRCS to all their eligible patients.
System barriers of visit type and time are closely linked and associated with physician recommendation of CRCS. This is consistent with 3 previous studies that demonstrate that health maintenance visits are a significant predictor of cancer screening.45–47
Thus, a modifiable system intervention is to reimburse providers for the time spent on preventive health counseling similar to the Medicare Part B “Welcome to Medicare” physical, which reimburses providers for a visit devoted to education and counseling about the preventive services.48
In addition, financial incentives provided by insurers to patients for completion of age-appropriate screening, as discussed by one of the participating physicians above, have been shown to be an effective intervention for increasing patient request of CRCS.49
The inability to track down dates of prior screening can be addressed with software programs that create electronic patient registries such as the Comorbid Disease Management Database (COMMAND) developed by the Mississippi Quality Improvement Organization.50
Hemoccult card kits can be placed in all the patient rooms to serve as a cue to action for physicians. Finally, paramedical personnel can be trained to discuss the risk and benefits of and conduct cancer-screening tests to address the barrier of lack of physician time.51–53
The limitations of this study include that slightly over half of the physicians invited to participate refused or did not respond, introducing the possibility of bias. For example, participating physicians may have been more interested in preventive health, which may have prevented us from uncovering all the barriers to the recommendation of CRCS. In addition, the relatively small number of participating physicians and setting of the study in 2 large health systems in 1 city may also limit the generalizability of our findings. Finally, although physicians were required to pull a retrospective sequential sample of their charts for chart-stimulated recall before the interview and they did not learn that this study was about CRCS until after they had pulled their charts, it is possible that there was selection bias when choosing charts for discussion. Despite these limitations, the results provide new knowledge of circumstances that prevent or facilitate physician recommendation of CRCS. An additional strength is that the methods used in this study address the potential shortcomings of physician recall bias about their own counseling behavior. Finally, chart-stimulated recall was a feasible method to validate interview data and helped address the well-described discrepancy between physicians’ perceived and actual behavior related to recommending cancer screening tests,26,54,55
as well as recording bias inherent in methods based on chart abstraction.56–58
Overall, the finding that there are multiple modifiable barriers to and facilitators of physician recommendation of CRCS should guide investigators in designing patient- and physician-targeted educational and system interventions that increase physician recommendation of CRCS.