Explaining Physician Rates of Providing Flexible Sigmoidoscopy 1 Daniel E. Montan ˜o, 2 William R. Phillips, and Danuta Kasprzyk Battelle, Centers for Public Health Research and Evaluation, Seattle, Washington 98105 [D. E. M., W. R. P., D. K.], and Department of Family Medicine, University of Washington, Seattle, Washington 98195 [W. R. P.] Abstract Colorectal cancer is the third most frequent cancer, yet screening rates for this cancer remain low. This study was designed to identify factors associated with family physicians’ rates of recommending or providing flexible sigmoidoscopy. We applied a behavioral model consisting of three components: physician attitude toward providing the test, facilitating conditions, and reinforcing conditions. Qualitative interviews identified relevant measures of each model component and guided the design of the survey. The survey was administered to 60 randomly selected family physicians in Washington State. Chart reviews were conducted to measure physician rates of providing flexible sigmoidoscopy. All three model components were significantly correlated with sigmoidoscopy rate. Multiple regression found physician attitude, facilitating conditions, and their interaction to be significant determinants of sigmoidoscopy rate (multiple R  0.72). Analyses of specific items used to measure physician attitude found that physician beliefs about cost, time, income, degree of distaste, risk of complications, and screening effectiveness were significantly correlated with sigmoidoscopy rate. Specific facilitating conditions found to be correlated with rate of providing the test included physician and staff training, availability of a reminder system, and clinic structural conditions. This study provides strong support for application of a theory- based model to understand physician provision of flexible sigmoidoscopy testing for colorectal cancer. The findings provide very specific information to guide development of educational and motivational efforts and modification of facilitating conditions to increase physician provision of sigmoidoscopy to control colorectal cancer. Introduction Colorectal cancer is the third most frequent form of cancer and the second leading cause of cancer-related deaths among both men and women in the United States. Survival of patients with localized disease is extremely good (1–3). However, most (60%) patients have regional or distant metastases at the time of colorectal cancer diagnosis (4). Early detection and removal of precancerous polyps allow patients to recover without moving on to a diagnosis of cancer, whereas early detection and re- moval of cancerous polyps positively impacts survival rates (1, 2). Regular colorectal cancer screening among individuals age 50 years and older has great potential for both primary and secondary cancer prevention. Routine sigmoidoscopic screening every 3–5 years begin- ning at age 50 has been recommended since the 1980s by the American Cancer Society, the National Cancer Institute, and other organizations (5). In a 1993 review, Ransohoff and Lang (6) concluded that although sigmoidoscopic screening had been recommended for over a decade, it has been widely ignored by physicians and patients. A recent task force sponsored by the AHCPR 3 and a consortium of five gastrointestinal groups, led by the American Gastroenterological Association, reviewed the evidence to date and released new colorectal cancer screening guidelines that include flexible sigmoidoscopy every 3–5 years (1). Subsequently, the American Cancer Society issued an update of its 1993 guidelines, which were in agreement with the AHCPR recommendations (7). The USPSTF now also recom- mends periodic flexible sigmoidoscopy screening of patients ages 50 and older (8). National surveys indicate that colorectal cancer screening rates in the United States are disappointingly low, with between 26 and 40% of respondents reporting ever having had a proc- toscopy or sigmoidoscopy (1, 2). Primary care physicians play a critical role in recommending and encouraging patient ac- ceptance of this test. Patient compliance is associated with physician recommendation and how well the physician explains the importance of flexible sigmoidoscopy (9 –11). However, current research indicates that this test continues to be viewed as controversial by primary care physicians (12). Thus, it is essential to understand the factors affecting physician recom- mendation and offering of flexible sigmoidoscopy to design effective intervention strategies to increase provision of the test (1). Unfortunately, only a few studies to date have examined factors affecting clinician provision of flexible sigmoidoscopy. Some studies have assessed clinician screening policies and practices or assessed the association between physician char- acteristics and belief in effectiveness of the test (13, 14). Other studies have assumed that system barriers are most important in determining provision of flexible sigmoidoscopy and have in- vestigated the prevalence of or strategies to overcome those barriers (11, 15–17). Although some studies have surveyed physicians to identify characteristics associated with their rec- ommendation of the test, they have focused on practice and demographic characteristics rather than physician opinions (14, 18). Some studies have asked physicians to indicate whether Received 2/2/99; revised 3/29/00; accepted 4/13/00. The costs of publication of this article were defrayed in part by the payment of page charges. This article must therefore be hereby marked advertisement in accordance with 18 U.S.C. Section 1734 solely to indicate this fact. 1 Supported by Grant CA47805 from the National Cancer Institute. 2 To whom requests for reprints should be addressed, at Battelle, 4500 Sand Point Way N.E., Seattle, WA 98105. 3 The abbreviations used are: AHCPR, Agency for Health Care Policy Research; USPSTF, United States Preventive Services Task Force; TPB, theory of planned behavior; ACS, American Cancer Society. 665 Vol. 9, 665– 669, July 2000 Cancer Epidemiology, Biomarkers & Prevention on January 25, 2022. © 2000 American Association for Cancer Research. cebp.aacrjournals.org Downloaded from