Primary Care, Economic Barriers to Health Care, and Use of Colorectal Cancer Screening Tests Among Medicare Enrollees Over Time

Chyke A. Doubeni; Adeyinka O. Laiyemo; Angela C. Young; Carrie N. Klabunde; George Reed; Terry S. Field; Robert H. Fletcher

doi:10.1370/afm.1112

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Access to Primary Care and Colorectal Cancer Screening
Joshua J Fenton

Published on: 29 July 2010
Overcoming Barriers to CRC Screening in Primary Care
Chyke A Doubeni

Published on: 22 July 2010

Published on: (29 July 2010)
Page navigation anchor for Access to Primary Care and Colorectal Cancer Screening
Access to Primary Care and Colorectal Cancer Screening
Joshua J Fenton, Sacramento, CA
Doubeni et al. demonstrate that lack of a “usual source of care” constitutes a substantial barrier to colorectal cancer (CRC) screening for approximately 5.5% of Medicare enrollees. Such patients are also much less likely to receive other effective preventive services (1).
As Doubeni et al. acknowledge, access to primary care may be a necessary condition for CRC screening delivery, but it is not sufficient. Ind...
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Doubeni et al. demonstrate that lack of a “usual source of care” constitutes a substantial barrier to colorectal cancer (CRC) screening for approximately 5.5% of Medicare enrollees. Such patients are also much less likely to receive other effective preventive services (1).
As Doubeni et al. acknowledge, access to primary care may be a necessary condition for CRC screening delivery, but it is not sufficient. Indeed, most unscreened patients attend regular primary care visits, and an absence of primary care visits probably accounts for a small fraction of the overall burden of underscreening (2). At a population level, a greater impact on overall screening rates would probably be achieved by increasing the delivery of CRC screening during primary care visits that patients already attend.
Dr. Doubeni offers several worthwhile suggestions for achieving this goal. Family physicians can implement some of these with little cost or effort, while others, such as registries or reminder systems, may entail significant costs, including opportunity costs (if a focus on CRC screening leads to reduced attention to other important services). Whether patient navigators could successfully assist patients in CRC screening completion seems an open research question. But is it economically or practically feasible to navigate patients toward achieving all of the many worthwhile but underachieved health care outcomes?
It is worth noting that population-based promotion programs have achieved high degrees of population uptake of other cancer screening tests, such as mammography and Pap smear screening (3, 4). Although patients may respond favorably to the recommendations of personal physicians, widespread uptake of CRC screening may require a multi-pronged approach, including activation of the primary care workforce and adroit public health messaging and outreach.
References
1. DeVoe JE, Fryer GE, Phillips R, Green L. Receipt of preventive care among adults: insurance status and usual source of care. Am J Public Health. 2003 May;93(5):786-91.
2. Fenton JJ, Reid RJ, Baldwin LM, Elmore JG, Buist DS, Franks P. Influence of primary care on population delivery of colorectal cancer screening. Cancer Epidemiol Biomarkers Prev. 2009 Feb;18(2):640-5.
3. Thompson RS, Taplin SH, McAfee TA, Mandelson MT, Smith AE. Primary and secondary prevention services in clinical practice. Twenty years' experience in development, implementation, and evaluation. JAMA. 1995 Apr 2;273(14):1130-5.
4. Olsson S, Andersson I, Karlberg I, Bjurstam N, Frodis E, Håkansson S. Implementation of service screening with mammography in Sweden: from pilot study to nationwide programme. J Med Screen. 2000;7(1):14-8.
Competing interests: None declared
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Competing Interests: None declared.
Published on: (22 July 2010)
Page navigation anchor for Overcoming Barriers to CRC Screening in Primary Care
Overcoming Barriers to CRC Screening in Primary Care
Chyke A Doubeni, Worcester, MA, USA
The recent report to the nation on cancer highlighted the critical role of screening in reducing death from colorectal cancer. Screening can prevent colorectal cancers or detect them at an earlier more treatable stage. Unfortunately, far too many cancers are still being diagnosed at advanced less curable stages. The screening process is complex and requires multiple steps, each of which has the potential to undermine our goal...
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The recent report to the nation on cancer highlighted the critical role of screening in reducing death from colorectal cancer. Screening can prevent colorectal cancers or detect them at an earlier more treatable stage. Unfortunately, far too many cancers are still being diagnosed at advanced less curable stages. The screening process is complex and requires multiple steps, each of which has the potential to undermine our goal of increasing the use of colorectal cancer screening. This study highlighted critical role of primary care providers in colorectal cancer screening and identified several barriers to screening that should be addressed by physician practices. Assuring access to colon cancer screening for less educated and underinsured patients should be part of the goal of primary care redesign in the context of the patient-centered medical home.
In my view, there are three broad groups of patients. The first group is people who will get screened even in the absence of a physician recommendation. We just need to make sure the services are available. The main concern for this group is overuse of the services such as colonoscopy. The second group is people who will get screened if prompted by a physician recommendation. Explanation of the procedure and clear directions about the recommended test along with plans on follow-up of test results are needed. They also need to be reminded when screening is next due. The third group, about 30%, is mostly comprised of patients who tend to have lower income and education and inadequate insurance. They may not have a primary care home or regular visits with their doctors. In addition to previously outlined steps, effectiveness in promoting screening for this latter group requires systems in place to support cancer screening by overcoming financial, physical and cultural barriers. This may involve collaboration with community partners and use of navigators.
What are some things that providers can do right now to improve use of colorectal cancer screening?
1) Know your patient population and understand their needs.
2) Know the resources available to your community and practice
3) Identify patients at higher risk through simple personal and family history.
4) Know and offer all the available testing options. “The best test is the one that gets done.”
5) Know the social and economic barriers for your patients and involve them in the decision about the most appropriate screening test on an individual basis
6) Have a system for tracking who is eligible for screening and the frequency of testing on an individualized basis
7) Have a system for tracking the results of screening tests
Competing interests: None declared
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Competing Interests: None declared.