Association Between Primary Care Visits and Colorectal Cancer Screening Outcomes in the Era of Population Health Outreach

Published in: Journal of General Internal Medicine, 2016

Posted on RAND.org on June 24, 2016

by Ethan A. Halm, Elisabeth F. Beaber, Dale McLerran, Jessica Chubak, Douglas A. Corley, Carolyn M. Rutter, Chyke A. Doubeni, Jennifer S Haas, Bijal A. Balasubramanian

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Research Questions

  1. Are patients who visit their primary care provider more likely to be screened for colorectal cancer (CRC)?
  2. Are patients more likely receive a colonoscopy after a positive CRC screening result?

Background

Population outreach strategies are increasingly used to improve colorectal cancer (CRC) screening. The influence of primary care on cancer screening in this context is unknown.

Objective

To assess associations between primary care provider (PCP) visits and receipt of CRC screening and colonoscopy after a positive fecal immunochemical (FIT) or fecal occult blood test (FOBT).

Design

Population-based cohort study.

Participants

A total of 968,072 patients ages 50–74 years who were not up to date with CRC screening in 2011 in four integrated healthcare systems (three with screening outreach programs using FIT kits) in the Population-Based Research Optimizing Screening through Personalized Regimens (PROSPR) consortium.

Measures

Demographic, clinical, PCP visit, and CRC screening data were obtained from electronic health records and administrative databases. We examined associations between PCP visits in 2011 and receipt of FIT/FOBT, screening colonoscopy, or flexible sigmoidoscopy (CRC screening) in 2012 and follow-up colonoscopy within 3 months of a positive FIT/FOBT in 2012. We used multivariable logistic regression and propensity score models to adjust for confounding.

Results

Fifty-eight percent of eligible patients completed a CRC screening test in 2012, most by FIT. Those with a greater number of PCP visits had higher rates of CRC screening at all sites. Patients with ≥1 PCP visit had nearly twice the adjusted-odds of CRC screening (OR = 1.88, 95 % CI: 1.86–1.89). Overall, 79.6 % of patients with a positive FIT/FOBT completed colonoscopy within 3 months. Patients with ≥1 PCP visit had 30 % higher adjusted odds of completing colonoscopy after positive FIT/FOBT (OR = 1.30; 95 % CI: 1.22–1.40).

Conclusions

Patients with a greater number of PCP visits had higher rates of both incident CRC screening and colonoscopy after positive FIT/FOBT, even in health systems with active population health outreach programs. In this era of virtual care and population outreach, primary care visits remain an important mechanism for engaging patients in cancer screening.

Key Findings

  • Patients with higher rates of visits to primary care providers (PCPs) also had higher rates of colorectal cancer screening and follow-up colonoscopies after a positive screening result.

Limitations

  • Patients who are more prevention oriented may be more likely to visit their PCPs, and therefore more likely to complete screening.
  • Multiple visits to PCPs may "prime" patients to overcome their initial objections to screening, or respond to screening reminders from institutional outreach efforts.
  • Primary care visits seem to be more effective than institutional outreach efforts in getting patients to complete screening.

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