Survey data collected from the 5 Arkansas public health regions expand the scientific literature on population-based colorectal cancer screening programs and provided a foundation for investigators and stakeholders to develop recommendations for a state-sponsored screening program. The study makes 3 novel contributions. One, we used categorical variables to examine vulnerable population segments relevant to the design and implementation of a state-sponsored colorectal screening program. Two, the higher screening rate found among blacks compared with whites when we controlled for screening advice provides new insight on the importance of promoting physician advice within a screening program intended to reduce disparities. Three, our process established a heuristic model for integrating state-specific data with general evidence-based guidelines to engage local stakeholders in efforts to inform a screening program.
Our study resulted in 3 recommendations for a screening program that is responsive to medically underserved populations in Arkansas and consistent with guidelines published by the Centers for Disease Control and Prevention (16
). One, establish state legislation that addresses reimbursement for colorectal cancer screening. Lower screening rates among unemployed and low-income participants suggest that cost may be a barrier to screening. Higher screening rates among Medicare-eligible participants relative to their counterparts aged 50 to 64 suggest that financial incentives for health care professionals and a reduction in out-of-pocket expenses for patients would increase screening rates. These findings are consistent with national data (4
) and suggest that state-sponsored reimbursement may enhance population screening rates. Grass roots, health policy, and legislative stakeholders used state-specific data to establish the Arkansas Colorectal Cancer Prevention, Early Detection, and Treatment Act of 2009, which defines screening methods for a state-sponsored program. Survey data also were used by a community-based coalition to secure legislative appropriations to fund a pilot program that screens approximately 165 community residents per year.
Two, use primary care providers as a point of entry in population-based screening efforts. Consistent with studies reporting a strong association between physician recommendations and colorectal cancer screening (12
), our study showed that health provider advice predicted various measures of screening status. Physician advice can be an effective point of entry for population-based screening efforts. Our data, which showed that 83.6% of participants had a health care provider and 35.5% had 5 or more health care visits in the previous year, support the feasibility of recommendations to integrate colorectal screening programs into existing clinical structures (7
). Although a smaller proportion of blacks than whites in our study had a health care provider, 78.7% had a primary care provider and 40.4% had 5 or more health care visits in the previous year. That black participants were more likely than white participants to be in compliance with screening guidelines when controlling for physician advice differs from previous findings (4
). Physician advice during routine health care visits can serve as an effective point of entry to a screening program for this population. The Arkansas pilot screening program reimburses specialists who provide endoscopic screening and primary care providers who identify screening-eligible patients, provide screening recommendations, and either initiate FOBT or refer patients for endoscopic screening.
Three, promote a balanced approach to screening recommendations. Because many physician recommendations do not necessarily result in colorectal screening (18
), screening programs should be structured to enhance the effect of physician advice. Reliance on colonoscopy may not support adequate screening at the population level (4
); 18.6% of our sample received physician advice for FOBT, whereas 51.3% received advice for colonoscopy. Population-based screening programs need to promote a more balanced approach (ie, multiple options) to screening recommendations. A balanced approach is important because limited access to gastroenterologists is linked with a high incidence of late-stage colorectal cancer in rural areas (20
). Data showing a concentration of vulnerable populations and low screening rates in 3 rural public health regions of the state (10
) underscore the importance of promoting a more balanced approach. Evidence that self-reported data overestimate screening rates (21
) suggests that our data may underestimate the magnitude of the problem in rural public health regions. Based on policy initiatives recommending third-party reimbursement for all evidence-based screening methods (3
) and state data demonstrating low screening rates in rural areas that have limited access to endoscopic screening, the Arkansas Colorectal Cancer Prevention, Early Detection, and Treatment Act of 2009 included language authorizing reimbursement for all evidence-based screening methods to make FOBT and endoscopic procedures equally available.
That black participants were less likely than white participants to report receiving physician advice may reflect physician expectations about patient interest or ability to pay for screening (22
). Our study showed that a larger proportion of blacks than whites reported that physicians do not spend enough time during visits and do not involve them in health care decisions. Time spent with a physician and adequate understanding of physician recommendations predict screening (14
); differences in time spent and involvement in decision making may contribute to disparities in screening. The Arkansas Colorectal Cancer Prevention, Early Detection, and Treatment Act of 2009 included language that called for activities to improve professional skills for enhancing the detection and control of colorectal cancer. Our study shows a need to promote knowledge and attitudes among health professionals that will help incorporate screening recommendations as a component of routine health care visits. Professional education is needed to increase awareness of state policies and resources for no-cost or minimal-cost screening for eligible participants, guidelines for multiple screening methods, and the importance of involving patients in health care decisions. Reimbursement to primary care providers for a health care visit that addresses screening recommendations may help support this recommendation.
This study has several limitations. Results and recommendations are based on self-reported data and are constrained by the limitations inherent in population-based surveys. Although the collection and application of state-specific data have been integral components of a collaborative process to establish population-based screening, demonstration of the effect of legislation and policies on colorectal cancer screening, incidence, or death rates does not fall within the scope of this study, and we cannot claim or measure any cause or effect. Recommendations for population-based screening in Arkansas have potential relevance for populations that have similar demographic profiles, but study results and policy outcomes may not generalize to other settings.
Our survey informed efforts to decrease disparities in colorectal cancer screening in Arkansas. State-specific data were used in conjunction with evidence-based guidelines to engage local stakeholders in a novel initiative to promote colorectal cancer screening. Grass roots, health policy, and legislative stakeholders collaborated to establish legislation intended to provide financial incentives for health care professionals to reduce out-of-pocket expenses for patients and promote a more balanced approach to screening. This process provides a heuristic model for others who wish to implement a population-based screening program that addresses colorectal cancer disparities.