VA Health Services Research & Development Center of Excellence on Implementing Evidence-Based Practice, Richard L. Roudebush VA Medical Center, 1481 West 10th St. (11H), Indianapolis, IN 46202, USA.
J Gen Intern Med. 2013 Jan;28(1):18-24. doi: 10.1007/s11606-012-2093-6. Epub 2012 Jun 1.
Screening patterns among primary care physicians (PCPs) may be influenced by patient age and comorbidity. Colorectal cancer (CRC) screening has little benefit among patients with limited life expectancy.
To characterize the extent to which PCPs modify their recommendations for CRC screening based upon patients' increasing age and/or worsening comorbidity
Cross-sectional, nationally representative survey.
The study comprised primary care physicians (n = 1,266) including general internal medicine, family practice, and obstetrics-gynecology physicians.
Physician CRC screening recommendations among patients of varying age and comorbidity were measured based upon clinical vignettes. Independent variables in adjusted models included physician and practice characteristics.
For an 80-year-old patient with unresectable non-small cell lung cancer (NSCLC), 25 % of PCPs recommended CRC screening. For an 80-year-old patient with ischemic cardiomyopathy (New York Heart Association, Class II), 71 % of PCPs recommended CRC screening. PCPs were more likely to recommend fecal occult blood testing than colonoscopy as the preferred screening modality for a healthy 80-year-old, compared to healthy 50- or 65-year-old patients (19 % vs. 5 % vs. 2 % p < 0.001). For an 80-year-old with unresectable NSCLC, PCPs who were an obstetrics-gynecology physician were more likely to recommend CRC screening, while those with a full electronic medical record were less likely to recommend screening.
PCPs consider comorbidity when screening older patients for CRC and may change the screening modality from colonoscopy to FOBT. However, a sizable proportion of PCPs would recommend screening for patients with advanced cancer who would not benefit. Understanding the mechanisms underlying these patterns will facilitate the design of future medical education and policy interventions to reduce unnecessary care.
初级保健医生（PCP）的筛查模式可能会受到患者年龄和合并症的影响。对于预期寿命有限的患者，结直肠癌（CRC）筛查的获益很小。
描述 PCP 根据患者年龄的增加和/或合并症的恶化程度，调整 CRC 筛查建议的程度。
横断面、全国代表性调查。
研究包括初级保健医生（n=1266），包括普通内科、家庭医学和妇产科医生。
根据临床病例描述测量不同年龄和合并症患者的医生 CRC 筛查建议。调整后的模型中的自变量包括医生和实践特征。
对于一位患有不可切除的非小细胞肺癌（NSCLC）的 80 岁患者，25%的 PCP 建议进行 CRC 筛查。对于一位患有缺血性心肌病（纽约心脏协会，II 级）的 80 岁患者，71%的 PCP 建议进行 CRC 筛查。与健康的 50 岁或 65 岁患者相比，PCP 更倾向于推荐粪便潜血试验而不是结肠镜检查作为健康 80 岁患者的首选筛查方式（19%比 5%比 2%，p<0.001）。对于一位患有不可切除 NSCLC 的 80 岁患者，妇产科医生更有可能建议进行 CRC 筛查，而那些拥有完整电子病历的医生则不太可能建议进行筛查。
PCP 在为老年患者筛查 CRC 时会考虑合并症，并且可能会将筛查方式从结肠镜检查改为 FOBT。然而，相当一部分 PCP 会建议对没有获益的晚期癌症患者进行筛查。了解这些模式背后的机制将有助于设计未来的医学教育和政策干预措施，以减少不必要的医疗。
