Levy Barcey T, Nordin Terri, Sinift Suzanne, Rosenbaum Marcy, James Paul A
Department of Family Medicine, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City 52242, USA.
J Am Board Fam Med. 2007 Sep-Oct;20(5):458-68. doi: 10.3122/jabfm.2007.05.070058.
Less than half of eligible Americans have been screened for colorectal cancer (CRC). The objective of this study was to describe physicians' reasons for screening or not screening specific patients for CRC and their approach to CRC testing discussions.
This study used mixed-methods. Physicians described their reasons for screening or not screening 6 randomly chosen patients who were eligible for CRC screening (3 screened and 3 not screened) whose CRC testing status was ascertained by medical record review. Verbatim transcripts from physicians responding to structured interview questions were used to identify themes. Specific elements of discussion were examined for their association with each physician's screening rate. Fifteen randomly chosen Iowa family physicians from the Iowa Research Network stratified by privileges to perform colonoscopy, flexible sigmoidoscopy, or neither procedure dictated the reasons why 43 patients were screened and 40 patients were not screened.
Reasons patients were not up to date fell into 2 major categories: (1) no discussion by physician (50%) and (2) patient refusal (43%). Reasons for no discussion included lack of opportunity, assessment that cost would be prohibitive, distraction by other life issues/health problems, physician forgetfulness, and expected patient refusal. Patients declined because of cost, lack of interest, autonomy, other life issues, fear of screening, and lack of symptoms. Patients who were up to date received (1) diagnostic testing (for previous colon pathology or symptoms; 56%) or (2) asymptomatic screening (44%). Physicians who were more adamant about screening had higher screening rates (P<.05; Wilcoxon rank sum). Physicians framed their recommendations differently ("I recommend" vs "They recommend"), with lower screening rates among physicians who used "they recommend" (P=.05; Wilcoxon rank sum).
Reasons many patients remain unscreened for CRC include (1) factors related to the health care system, patient, and physician that impede or prevent discussion; (2) patient refusal; and (3) the focus on diagnostic testing. Strategies to improve screening might include patient and physician education about the rationale for screening, universal coverage for health maintenance exams, and development of effective tracking and reminder systems. The words physicians choose to frame their recommendations are important and should be explored further.
符合条件的美国人中，接受过结直肠癌（CRC）筛查的不到一半。本研究的目的是描述医生对特定患者进行或不进行CRC筛查的原因以及他们进行CRC检测讨论的方式。
本研究采用混合方法。医生描述了他们对6名随机选择的符合CRC筛查条件患者（3名接受了筛查，3名未接受筛查）进行或不进行筛查的原因，这些患者的CRC检测状态通过病历审查确定。医生对结构化访谈问题的逐字记录用于确定主题。检查讨论的具体内容与每位医生筛查率的关联。从爱荷华研究网络中随机选择15名爱荷华州家庭医生，根据进行结肠镜检查、乙状结肠镜检查或两种检查都不进行的特权进行分层，他们说明了43名患者接受筛查和40名患者未接受筛查的原因。
患者未及时进行筛查的原因分为两大类：（1）医生未进行讨论（50%）和（2）患者拒绝（43%）。未进行讨论的原因包括缺乏机会、认为费用过高、被其他生活问题/健康问题分心、医生遗忘以及预期患者会拒绝。患者拒绝的原因包括费用、缺乏兴趣、自主性、其他生活问题、害怕筛查以及没有症状。及时进行筛查的患者接受了（1）诊断性检测（针对既往结肠病变或症状；56%）或（2）无症状筛查（44%）。对筛查更坚定的医生筛查率更高（P<0.05；Wilcoxon秩和检验）。医生提出建议的方式不同（“我建议”与“他们建议”），使用“他们建议”的医生筛查率较低（P=0.05；Wilcoxon秩和检验）。
许多患者未接受CRC筛查的原因包括：（1）与医疗保健系统、患者和医生相关的阻碍或阻止讨论的因素；（2）患者拒绝；以及（3）对诊断性检测的关注。改善筛查的策略可能包括对患者和医生进行筛查基本原理的教育、健康维护检查的全民覆盖以及开发有效的跟踪和提醒系统。医生选择用来提出建议的措辞很重要，应进一步探讨。
