CRC Screening Variation Among PCPs and Clinics
CRC Screening Variation Among PCPs and Clinics
The most common CRC screening modality in our health-care system was optical colonoscopy (86%). CT colonography (8%) and FOBT (4%) were used infrequently, and flexible sigmoidoscopy and double contrast barium enema almost never.
Over 34,000 patients were identified as eligible for CRC screening in 2009 according to the methodology previously described. The majority of patients were between 50 and 60 years of age, 58% were women, 93% were white, most were married, 94% speak English as their primary language, and more than two-thirds had commercial insurance coverage (Table 1). For the 97 PCPs, 49% were female, over half practice in Internal Medicine (59%) with 41% in Family Medicine, >50% have been in practice for more than 20 years, and the average number of patients in a provider's panel that are eligible for CRC screening is over 480. On average, PCPs perceived more major barriers to CRC screening to exist at the patient level compared with the provider and system levels. Two-thirds of the primary-care clinics were physician-owned (as compared with hospital-owned), the average number of providers caring for patients eligible for CRC screening in each clinic was 10, and the average distance of the clinics to the nearest optical colonoscopy facility was 6.5 miles.
All patients were assigned to PCPs using the plurality provider algorithm described by Pham et al.. PCPs were assigned to clinics by the clinic at which the provider billed most of his or her Evaluation & Management visits during the year. Seventy-one percentage of patients (N=24,372) completed their CRC screening and 29% (N=9,947) were not screened (Table 2). Significant differences were observed between the screened and not screened patients in patient, provider, and clinic variables. Although statistically significant owing to the large sample size, some of these differences were not clinically significant (e.g., patient race).
Patient Variables. Patients who completed screening were older (48% of screened patients were between 60 and 75 years old vs. 45% of patients who were not screened, P<0.001), more often white (94 vs. 92%, P<0.001), more often married (74 vs. 65%, P<0.001), spoke English as a primary language (95 vs. 91%, P<0.001), had more commercial insurance coverage (74 vs. 68%, P<0.001), and more health-care resource utilization (Ambulatory Care Group Resource Utilization Score of 0.6 vs. 0.5, P<0.001).
Provider Variables. Patients who were screened were more likely to be seen by PCPs who have been in practice longer (87% of screened patients are seen by PCPs who have been in practice for ≥10 years vs. 83% of patients who were not screened, P<0.001), are female (50 vs. 48%, P=0.01), practice Internal Medicine (63 vs. 50%, P<0.001), and have larger panels of patients eligible for CRC screening (500 vs. 460, P<0.001). Patients who completed screening were also seen by PCPs who perceived more major barriers to CRC screening at the patient and system levels (2.5 vs. 2.3, P<0.001 and 1.8 vs. 1.6, P<0.001, respectively).
Clinic Variables. Patients who were screened were significantly more likely to receive their primary care at a hospital-owned clinic (36 vs. 26%, P<0.001) and a clinic that is closer to the nearest optical colonoscopy center (6.2 vs. 7.2 miles, P<0.001).
Variation in CRC screening rates was seen across 19 primary-care clinics within the health system (Figure 1). CRC screening rates by primary-care clinic ranged from 51 to 80%.
(Enlarge Image)
Figure 1.
Variation in CRC screening rates by primary-care clinic in 2009. Each bubble in the graph represents a separate primary-care clinic and the size of the bubble corresponds to the relative size of that clinic's eligible patient population. Data from providers with < 100 eligible patients and clinics with < 300 eligible patients were excluded.
Variation in CRC screening rates also existed among PCPs across the system and within each clinic (Figure 2). CRC screening rates by PCP ranged from 51–82% in the clinic with the largest spread, compared with a range of 60–64% in the clinic with the smallest spread.
(Enlarge Image)
Figure 2.
Variation in CRC screening rates by PCP within primary-care clinics in 2009. Each blue bubble in the graph represents an individual PCP and the size of the bubble corresponds to the relative size of that provider's eligible patient population. Providers within the same primarycare clinic are arranged vertically. The red X for each clinic represents the average CRC screening rate for that clinic. Data from providers with < 100 eligible patients and clinics with < 300 eligible patients were excluded.
Logistic regression with clustering on clinics, controlling for all patient, provider, and clinic variables, revealed significant predictors of CRC screening variation at each level. Significant patient-level predictors for completing screening were increasing age, White race, being married, primarily English speaking, having commercial insurance coverage, not having congestive heart failure or diabetes, and utilizing more health-care resources (Table 3). The only significant provider-level predictor of CRC screening completion after controlling for multiple patient and clinic factors was increasing panel size of patients eligible for CRC screening. Clinic-level predictors of CRC screening completion were that the clinic was hospital-owned rather than physician-owned, and shorter distance to the nearest optical colonoscopy center.
Results
CRC Screening Modalities
The most common CRC screening modality in our health-care system was optical colonoscopy (86%). CT colonography (8%) and FOBT (4%) were used infrequently, and flexible sigmoidoscopy and double contrast barium enema almost never.
Overall Sample Characteristics
Over 34,000 patients were identified as eligible for CRC screening in 2009 according to the methodology previously described. The majority of patients were between 50 and 60 years of age, 58% were women, 93% were white, most were married, 94% speak English as their primary language, and more than two-thirds had commercial insurance coverage (Table 1). For the 97 PCPs, 49% were female, over half practice in Internal Medicine (59%) with 41% in Family Medicine, >50% have been in practice for more than 20 years, and the average number of patients in a provider's panel that are eligible for CRC screening is over 480. On average, PCPs perceived more major barriers to CRC screening to exist at the patient level compared with the provider and system levels. Two-thirds of the primary-care clinics were physician-owned (as compared with hospital-owned), the average number of providers caring for patients eligible for CRC screening in each clinic was 10, and the average distance of the clinics to the nearest optical colonoscopy facility was 6.5 miles.
Sample Characteristics by Screening Status (Screened vs. not Screened)
All patients were assigned to PCPs using the plurality provider algorithm described by Pham et al.. PCPs were assigned to clinics by the clinic at which the provider billed most of his or her Evaluation & Management visits during the year. Seventy-one percentage of patients (N=24,372) completed their CRC screening and 29% (N=9,947) were not screened (Table 2). Significant differences were observed between the screened and not screened patients in patient, provider, and clinic variables. Although statistically significant owing to the large sample size, some of these differences were not clinically significant (e.g., patient race).
Patient Variables. Patients who completed screening were older (48% of screened patients were between 60 and 75 years old vs. 45% of patients who were not screened, P<0.001), more often white (94 vs. 92%, P<0.001), more often married (74 vs. 65%, P<0.001), spoke English as a primary language (95 vs. 91%, P<0.001), had more commercial insurance coverage (74 vs. 68%, P<0.001), and more health-care resource utilization (Ambulatory Care Group Resource Utilization Score of 0.6 vs. 0.5, P<0.001).
Provider Variables. Patients who were screened were more likely to be seen by PCPs who have been in practice longer (87% of screened patients are seen by PCPs who have been in practice for ≥10 years vs. 83% of patients who were not screened, P<0.001), are female (50 vs. 48%, P=0.01), practice Internal Medicine (63 vs. 50%, P<0.001), and have larger panels of patients eligible for CRC screening (500 vs. 460, P<0.001). Patients who completed screening were also seen by PCPs who perceived more major barriers to CRC screening at the patient and system levels (2.5 vs. 2.3, P<0.001 and 1.8 vs. 1.6, P<0.001, respectively).
Clinic Variables. Patients who were screened were significantly more likely to receive their primary care at a hospital-owned clinic (36 vs. 26%, P<0.001) and a clinic that is closer to the nearest optical colonoscopy center (6.2 vs. 7.2 miles, P<0.001).
CRC Screening Rates Among Primary-care Clinics
Variation in CRC screening rates was seen across 19 primary-care clinics within the health system (Figure 1). CRC screening rates by primary-care clinic ranged from 51 to 80%.
(Enlarge Image)
Figure 1.
Variation in CRC screening rates by primary-care clinic in 2009. Each bubble in the graph represents a separate primary-care clinic and the size of the bubble corresponds to the relative size of that clinic's eligible patient population. Data from providers with < 100 eligible patients and clinics with < 300 eligible patients were excluded.
CRC Screening Rates Among PCPs
Variation in CRC screening rates also existed among PCPs across the system and within each clinic (Figure 2). CRC screening rates by PCP ranged from 51–82% in the clinic with the largest spread, compared with a range of 60–64% in the clinic with the smallest spread.
(Enlarge Image)
Figure 2.
Variation in CRC screening rates by PCP within primary-care clinics in 2009. Each blue bubble in the graph represents an individual PCP and the size of the bubble corresponds to the relative size of that provider's eligible patient population. Providers within the same primarycare clinic are arranged vertically. The red X for each clinic represents the average CRC screening rate for that clinic. Data from providers with < 100 eligible patients and clinics with < 300 eligible patients were excluded.
Predictors of CRC Screening Variation
Logistic regression with clustering on clinics, controlling for all patient, provider, and clinic variables, revealed significant predictors of CRC screening variation at each level. Significant patient-level predictors for completing screening were increasing age, White race, being married, primarily English speaking, having commercial insurance coverage, not having congestive heart failure or diabetes, and utilizing more health-care resources (Table 3). The only significant provider-level predictor of CRC screening completion after controlling for multiple patient and clinic factors was increasing panel size of patients eligible for CRC screening. Clinic-level predictors of CRC screening completion were that the clinic was hospital-owned rather than physician-owned, and shorter distance to the nearest optical colonoscopy center.
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