Abstract
BACKGROUND: Colonoscopy has become a preferred colorectal cancer (CRC) screening modality. Little is known about why patients who are referred for colonoscopy do not complete the recommended procedures. Prior adherence studies have evaluated colonoscopy only in combination with flexible sigmoidoscopy, failed to differentiate between screening and diagnostic procedures, and have examined cancellations/no-shows, but not nonscheduling, as mechanisms of nonadherence.
METHODS: Sociodemographic predictors of screening completion were assessed in a retrospective cohort of 647 patients referred for colonoscopy at a major university hospital. Then, using a qualitative study design, a convenience sample of patients who never completed screening after referral (n=52) was interviewed by telephone, and comparisons in reported reasons for nonadherence were made by gender.
RESULTS: Half of all patients referred for colonoscopy failed to complete the procedure, overwhelmingly because of nonscheduling. In multivariable analysis, female sex, younger age, and insurance type predicted poorer adherence. Patient-reported barriers to screening completion included cognitive-emotional factors (e.g., lack of perceived risk for CRC, fear of pain, and concerns about modesty and the bowel preparation), logistic obstacles (e.g., cost, other health problems, and competing demands), and health system barriers (e.g., scheduling challenges, long waiting times). Women reported more concerns about modesty and other aspects of the procedure than men. Only 40% of patients were aware of alternative screening options.
CONCLUSIONS: Adherence to screening colonoscopy referrals is suboptimal and may be improved by better communication with patients, counseling to help resolve logistic barriers, and improvements in colonoscopy referral and scheduling mechanisms.
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References
Winawer S, Fletcher R, Rex D, et al. Colorectal cancer screening and surveillance: clinical guidelines and rationale-Update based on new evidence. Gastroenterology. 2003;124:544.
McLeod RS. Screening strategies for colorectal cancer: a systematic review of the evidence. Can J Gastroenterol. 2001;15:647.
JAMA. Trends in screening for colorectal cancer—United States, 1997 and 1999. Morb Mortal Wkly Rep. 2001;50:162.
Anderson WF, Guyton KZ, Hiatt RA, et al. Colorectal cancer screening for persons at average risk. J Natl Cancer Inst. 2002;94:1126.
Hou SI, Chen PH. Home-administered fecal occult blood test for colorectal cancer screening among worksites in Taiwan. Prev Med. 2004;38:78.
Vinker S, Nakar S, Rosenberg E, et al. The role of family physicians in increasing annual fecal occult blood test screening coverage: a prospective intervention study. Isr Med Assoc J. 2002;4:424.
Powe BD. Promoting fecal occult blood testing in rural African American women. Cancer Pract. 2002;10:139.
Friedman LC, Everett TE, Peterson L, et al. Compliance with fecal occult blood test screening among low-income medical outpatients: a randomized controlled trial using a videotaped intervention. J Cancer Educ. 2001;16:85.
Turner BJ, Weiner M, Yang C, et al. Predicting adherence to colonoscopy or flexible sigmoidoscopy on the basis of physician appointment-keeping behavior. Ann Intern Med. 2004;140:528.
Kelly RB, Shank JC. Adherence to screening flexible sigmoidoscopy in asymptomatic patients. Med Care. 1992;30:1029.
Bejes C, Marvel MK. Attempting the improbable: offering colorectal cancer screening to all appropriate patients. Fam Pract Res J. 1992;12:83.
Salwen WA, Basson MD. Effect of four-day psyllium supplementation on bowel preparation for colonoscopy: a prospective double blind randomized trial [ISRCTN76623768]. BMC Gastroenterol. 2004;4:2.
United States General Accounting Office. VA Health Care: More National Action Needed to Reduce Waiting Times, But Some Clinics Have Made Progres. Washington, DC: United States General Accounting Office; 2001.
Harewood GC, Lieberman DA. Colonoscopy practice patterns since introduction of medicare coverage for average-risk screening. 2004;2:72.
Subramanian S, Klosterman M, Amonkar MM, et al. Adherence with colorectal cancer screening guidelines: a review. Prev Med. 2004;38:536.
Chao A, Connell CJ, Cokkinides V, et al. Underuse of screening sigmoidoscopy and colonoscopy in a large cohort of US adults. Am J Public Health. 2004;94:1775.
Weinberg DS, Turner BJ, Wang H, et al. A survey of women regarding factors affecting colorectal cancer screening compliance. Prev Med. 2004;38:669.
Strauss A, Corbin J. Basis of Qualitative Research: Grounded Theory Procedures and Techniques. Newbury Park, CA: Sage Publications; 1990.
Esposito J, Campanelli PC, Rothgeb J, et al. Determining which questions are best: methodologies for evaluating survey questions. Presented at the Proceedings of the American Statistical Association (Survey Research Methods Section), Alexandria, Va, 1991.
Yeazel MW, Church TR, Jones RM, et al. Colorectal cancer screening adherence in a general population. Cancer Epidemiol Biomarkers Prev. 2004;13:654.
Zapka JG, Lemon SC, Puleo E, et al. Patient education for colon cancer screening: a randomized trial of a video mailed before a physical examination. Ann Intern Med. 2004;141:683.
Wardle J, Williamson S, McCaffery K, et al. Increasing attendance at colorectal cancer screening: testing the efficacy of a mailed, psychoeducational intervention in a community sample of older adults. Health Psychol. 2003;22:99.
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Denberg, T.D., Melhado, T.V., Coombes, J.M. et al. Predictors of nonadherence to screening colonoscopy. J GEN INTERN MED 20, 989–995 (2005). https://doi.org/10.1111/j.1525-1497.2005.00164.x
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DOI: https://doi.org/10.1111/j.1525-1497.2005.00164.x