CRC screening rates remain suboptimal and have not significantly improved over time, remaining at around 50%.20
In this study we found that almost two fifths of eligible patients did not report ever receiving a doctor’s recommendation for CRC testing. Yet, receipt of a doctor’s recommendation for screening remains one of the strongest predictors of CRC screening, 7-12
it is a necessary step in the process of getting screened, and is reported to be a powerful motivator by patients.21
Clearly more emphasis is needed to encourage physicians to strongly recommend screening. We also investigated factors associated with receipt of a recommendation and found that the strongest association with doctor recommendation for CRC testing was having a female physician, being a male patient, having better overall health status and previous gastrointestinal disease; having a Hispanic physician was associated with lower reported rates of receiving a recommendation. Thus, we have identified some possible targets for further research and for interventions to improve screening rates. However, it is also evident from other work that a broader strategy will be needed because rates of completion remain suboptimal even when a recommendation is made.22
We observed that two physician characteristics were associated with screening recommendations. Female physicians were far more likely to recommend screening compared to their male counterparts, and this supports the findings of a study amongst internal medicine residents23
that included only female patients. Our other finding was that patients having a Hispanic physician reported lower rates of receiving a recommendation for screening. However, the numbers are small, only 7 such physicians were reported by 37 subjects. Six of these physicians were residents, but we did not observe an effect of rank in our bivariate analyses, so this an unlikely explanation. According to the literature, when physicians are asked about barriers to doctor recommendation, they cite inconsistent recommendations, uncertainty about cost effectiveness,24
concerns about patient acceptance of the tests25
the financial costs to the patient9, 26, 27
that they feel that the patient does not understand the pros and cons of testing and will not be compliant,28
or because of competing demands and lack of awareness that the patient is due for screening.28
However, little is known about gender or racial/ethnic or cultural differences in these beliefs amongst physicians, further research in this area is warranted, so that these beliefs can be targeted for change.
The patient characteristic most strongly associated with receiving a doctor’s recommendation for screening was being male. We found one other study that investigated the effect of a patient’s gender on receiving a doctor’s recommendation for CRC screening.12
That study included both men and women and found that women were more likely to be offered one particular type of test for CRC screening (the fecal occult blood test), however, when all test types were taken into account, as in our study, there was not any difference in the receipt of a doctor recommendation between men and women. Studies assessing the relationship between gender and actual CRC screening have mixed findings, some studies in the past have suggested that females are more likely to test with fecal occult blood testing, and less likely to be tested by flexible sigmoidoscopy,29-31
however, more recent data suggests no differences in gender rates for CRC screening.32
In our main study we did not observe gender differences in CRC screening,13
suggesting that in our population, females are screening at the same rate as males, even though they are less likely to receive a doctor’s recommendation. This finding implies that a greater proportion of females are compliant with a doctor’s recommendation for screening, compared to males. This area certainly warrants more research and suggests that different approaches may be needed in male and female patients.
Our other main findings were that better overall health status is associated with higher reported rates of recommendation, and this is consistent with the literature.12
This suggests that physicians may not be addressing preventive health issues as much in patients with poorer health, because of competing demands or other disease priorities for the visit. This suggests that physicians may need extra support for recommending screening to those that have other illnesses or health issues. This is contrast to the finding that a history of GI disease is associated with higher rates of reporting a recommendation for screening, However, since the timing of the diagnosis relative to the recommendation is not known, it is unclear whether a GI diagnosis prompted more recommendations for testing or whether the presence of a GI diagnosis simply improved patient recall of the recommendation.
We found no association with patients’ age, race/ethnicity or other socioeconomic characteristics and a doctor’s recommendation for CRC screening. However, Wee et al12
found that younger patients, Hispanics, and those of lower educational level were less likely to receive doctor recommendation in a national sample. These differences in findings may be attributable to the fact that our low socioeconomic status sample had insurance and access to care, so this may have mitigated some of the sociodemographic differences observed in the other study.
We hypothesized that gender or racial/ethnic congruence could influence the likelihood of a recommendation for CRC screening, however we did not find this to be the case, This is in contrast to the findings of a study that found that African Americans with African American physicians were more likely to report receipt of BP checks, pap smears and cholesterol checks.33
This suggests other factors in the patient-provider interaction may be more important. Of note, we observed that two thirds of patient-physician combinations were not racial/ethnically congruent, whereas the majority were gender congruent, suggesting that a shared cultural background is less important in the doctor-patient relationship than gender type.
We had also hypothesized that those at high risk of CRC because of family history would report greater levels of doctor recommendation for CRC screening, but we did not observe this. This suggests that physicians either need more education about high risk groups, or need help in identifying those at increased risk.
Limitations of our study include the fact that we studied patients attending a family medicine clinic in an academic health center and these findings may not be generalizable to patients in community settings or individuals without access to primary care. We also relied on patient recall of receiving a doctor’s recommendation for CRC testing and this may be open to recall bias, although work suggests that information from patient recall and medical record abstraction are comparable in accuracy. In some situations, patient report may actually be more reliable than the medical record, for instance physicians severely under document counseling and educational advice.34, 35
The cross sectional nature of the study also precludes causal inferences. Although our response rate of 56% is a limitation of the study, we observed no differences between respondents and non respondents on age, gender or race/ethnicity, increasing our confidence in the representativeness of the sample. We used logistic regression to calculate odds ratios in this cross sectional study, a common practice in both epidemiologic and clinical research. However, there is some debate in the literature about the validity of this approach versus the use of poisson regression to calculate prevalence ratios.36,37
Some have suggested that this could lead to an overestimation of the effect in certain situations,36
whereas others have argued that this concern is offset by other advantages.37
A final point is that although we cannot distinguish between recommendations made for screening from those made for diagnosis of symptoms, the difference may not be important because both result in the patient being up to date for screening. The strengths of our study include the fact that we were able to study a diverse population while controlling for differences in health care access and health insurance status, that we studied the effect of both patient and physician characteristics together and were able to examine the contribution of different gender and racial/ethnic patient-physician combinations to recommendations for screening.
In conclusion, we found that rates of receipt of a doctor’s recommendation for CRC screening were suboptimal and were associated with having a female physician, being a male patient, having GI disease and better health status; having a Hispanic physician was associated with lower rates of reported physician recommendation. Clearly physicians need to be encouraged to improve rates of recommendation for CRC screening; further studies should also determine cultural and gender influences on physician behavior.