Evidence Report/Technology Assessment 

Number 190 

Enhancing the Use and Quality of Colorectal Cancer 

Screening 

Prepared for: 

Agency for Healthcare Research and Quality 

U.S. Department of Health and Human Services 

540 Gaither Road 

Rockville, MD 20850 

www.ahrq.gov 

Contract No. 290-2007-10056-I 

Prepared by: 

RTI International–University of North Carolina Evidence-based Practice Center 

Investigators 

Debra J. Holden, Ph.D. 

Russell Harris M.D., M.P.H. 

Deborah S. Porterfield, M.D., M.P.H. 

Daniel E. Jonas M.D., M.P.H. 

Laura C. Morgan, M.A. 

Daniel Reuland, M.D., M.P.H. 

Michael Gilchrist, M.D., M.P.H. 

Meera Viswanathan, Ph.D. 

Kathleen N. Lohr, Ph.D. 

Brieanne Lyda-McDonald, M.S.P.H. 

AHRQ Publication No. 10-E002 

February 2010 
This report is based on research conducted by the RTI International – University of North Carolina 

at Chapel Hill, North Carolina (RTI-UNC) Evidence-based Practice Center (EPC) under contract 

to the Agency for Healthcare Research and Quality (AHRQ), Rockville, MD (Contract No. 290­

2007-10056-I). The findings and conclusions in this document are those of the author(s) who are 

responsible for its contents; the findings and conclusions do not necessarily represent the views of 

AHRQ. Therefore, no statement in this article should be construed as an official position of the 

Agency for Healthcare Research and Quality or of the U.S. Department of Health and Human 

Services. 

The information in this report is intended to help health care decision-makers; patients and 

clinicians, health system leaders, and policymakers, make well-informed decisions and thereby 

improve the quality of health care services. This report is not intended to be a substitute for the 

application of clinical judgment. Decisions concerning the provision of clinical care should 

consider this report in the same way as any medical reference and in conjunction with all other 

pertinent information, i.e., in the context of available resources and circumstances presented by 

individual patients. 

This report may be used, in whole or in part, as the basis for development of clinical practice 

guidelines and other quality enhancement tools, or as a basis for reimbursement and coverage 

policies. AHRQ or U.S. Department of Health and Human Services endorsement of such 

derivative products may not be stated or implied. 
This document is in the public domain and may be used and reprinted without permission except 

those copyrighted materials noted for which further reproduction is prohibited without the 

specific permission of copyright holders. 

Suggested Citation: 

Holden, DJ, Harris, R, Porterfield, DS, Jonas, DE, Morgan, LC, Reuland, D, Gilchrist, M, 

Viswanathan, M, Lohr, KN, Lyda-McDonald, B. Enhancing the Use and Quality of Colorectal 

Cancer Screening. Evidence Report/Technology Assessment No.190. (Prepared by the RTI 

International–University of North Carolina Evidence-based Practice Center under Contract No. 

290-2007-10056-I.) AHRQ Publication No. 10-E-002. Rockville, MD: Agency for Healthcare 

Research and Quality. February 2010. 

No investigators have any affiliations or financial involvement (e.g., employment, 

consultancies, honoraria, stock options, expert testimony, grants or patents received or 

pending, or royalties) that conflict with material presented in this report. 
Preface 

The Agency for Healthcare Research and Quality (AHRQ), through its Evidence-Based 

Practice Centers (EPCs), sponsors the development of evidence reports and technology 

assessments to assist public- and private-sector organizations in their efforts to improve the 

quality of health care in the United States. The reports and assessments provide organizations 

with comprehensive, science-based information on common, costly medical conditions and new 

health care technologies. The EPCs systematically review the relevant scientific literature on 

topics assigned to them by AHRQ and conduct additional analyses when appropriate prior to 

developing their reports and assessments. 

To bring the broadest range of experts into the development of evidence reports and health 

technology assessments, AHRQ encourages the EPCs to form partnerships and enter into 

collaborations with other medical and research organizations. The EPCs work with these partner 

organizations to ensure that the evidence reports and technology assessments they produce will 

become building blocks for health care quality improvement projects throughout the Nation. The 

reports undergo peer review prior to their release. 

AHRQ expects that the EPC evidence reports and technology assessments will inform 

individual health plans, providers, and purchasers as well as the health care system as a whole by 

providing important information to help improve health care quality. 

We welcome comments on this evidence report. They may be sent by mail to the Task Order 

Officer named below at: Agency for Healthcare Research and Quality, 540 Gaither Road, 

Rockville, MD 20850, or by e-mail to epc@ahrq.gov. 

Carolyn M. Clancy, M.D. Jean Slutsky, P.A., M.S.P.H. 

Director Director, Centre for Outcomes and Evidence 

Agency for Healthcare Research and Quality Agency for Healthcare Research and Quality 

Jennifer Croswell, M.D., M.P.H. Beth A. Collins Sharp, R.N., Ph.D. 

Acting Director Director, EPC Program 

Office of Medical Applications of Research Agency for Healthcare Research and Quality 

National Institutes of Health 

Paris Watson Supriya Janakiraman M.D., M.P.H. 

Senior Advisor to the NIH Consensus EPC Program Task Order Officer 

Development Program Agency for Healthcare Research and Quality 

Office of Medical Applications of Research 

National Institutes of Health 

iii 
Structured Abstract 

Objectives. To conduct a systematic review of the use and quality (including underuse, 

overuse, and misuse) of appropriate colorectal cancer (CRC) screening, including factors 

associated with screening, effective interventions to improve screening rates, current capacity, 

and monitoring and tracking the use and quality. Trends in the use and quality of CRC screening 

tests is also presented. 

Data sources. We searched MEDLINE®, the Cochrane Library, and the Cochrane Central 

Trials Registry, supplemented by handsearches, for studies published in English from January 

1998 through September 2009. 

Review methods. We used standard Evidence-based Practice Center methods of dual review 

of abstracts, full text articles, abstractions, quality rating, and quality grading. We resolved 

disagreements by consensus. 

Results. We found multiple problems of underuse, overuse, and misuse of CRC screening. 

We identified a total of 116 articles for inclusion into the systematic review, including a total of 

72 studies qualified for inclusion for key question (KQ) 2, 21 for KQ 3, 12 for KQ 4, and 8 for 

KQ 5. A number of patient-level factors are associated with lower screening rates, including 

having low income or less education, being uninsured or of Hispanic or Asian descent, not being 

acculturated into the United States, and having less or reduced access to care. Being insured, of 

higher income or education, and non-Hispanic white, participating in other cancer screenings, 

having a family history of CRC or personal history of another cancer, as well as receiving a 

physician recommendation to be screened, are associated with higher screening rates. 

Interventions that effectively increased CRC screening with high strength of evidence include 

patient reminders, one-on-one interactions, eliminating structural barriers, and system-level 

changes. The largest magnitude of improvement came from one-on-one interactions and 

eliminating barriers. Purely educational small-media interventions do not improve screening 

rates. Evidence is mixed for decision aids, although certain designs may be effective. No studies 

tested interventions to reduce overuse or misuse of CRC screening. We found no studies that 

assessed monitoring systems for underuse, overuse, and misuse of CRC screening. Modeling 

studies, using various assumptions, show that if the United States were to adopt a colonoscopyonly approach to CRC screening and everyone were to agree to be screened in this way, it is 

likely that colonoscopy capacity would need to be substantially increased. 

Conclusions. Both CRC screening and patient-physician discussions of CRC screening are 

underused, and important problems of overuse and misuse also exist. Some interventions hold 

promise for improvement. The research priority is to design and test interventions to increase 

screening and CRC screening discussions, building on the effective approaches identified in this 

review, and tailored to specific population needs. In addition, new interventions to reduce 

overuse and misuse should be designed and tested, along with studies of ongoing monitoring 

systems that are linked to feedback and continued improvement efforts. 

v 

Contents 

Executive Summary.........................................................................................................................1
 

Evidence Report.............................................................................................................................9 

Chapter 1. Introduction ..................................................................................................................11
 

Development of Evidence and Recommendations for CRC Screening.................................... 11
 

Implementation of Guidelines: Use and Quality ...................................................................... 13
 

Scope of this Report.................................................................................................................. 14
 

Organization of this Report....................................................................................................... 15
 

Chapter 2. Methods........................................................................................................................17
 

Technical Expert Panel (TEP) .................................................................................................. 17
 

Key Questions and Analytic Framework.................................................................................. 17
 

Literature Search....................................................................................................................... 19
 

Study Selection Process ............................................................................................................ 19
 

Inclusion and Exclusion Criteria............................................................................................19
 

Literature Synthesis .................................................................................................................. 22
 

Data Abstraction ....................................................................................................................22
 

Rating Quality of Individual Studies .....................................................................................23
 

Grading Strength of Evidence................................................................................................23
 

Applicability ..........................................................................................................................24
 

Peer Review ...........................................................................................................................24
 

Chapter 3. Overview of Trends in Use and Quality of CRC Screening ........................................25
 

KQ 1: What are the Recent Trends in the Use and Quality of CRC Screening?...................... 25
 

Trends in Incidence and Mortality from Colorectal Cancer ..................................................25
 

Measures of CRC Screening..................................................................................................25
 

Changes in Medicare Coverage of CRC Screening...............................................................26
 

Changes Over Time in National Surveys of Screening .........................................................26
 

Estimates from NHIS and BRFSS .........................................................................................27
 

Population Subgroups ............................................................................................................27
 

Medical Practice Rates...........................................................................................................28
 

Frequency of Discussions about CRC Screening ..................................................................29
 

Test-Specific Trends ..............................................................................................................30
 

Patient Preferences for CRC Screening Tests........................................................................31
 

Geographic Differences .........................................................................................................32
 

Health System Rates ..............................................................................................................32
 

Overuse of CRC Screening....................................................................................................32
 

Misuse Rates ..........................................................................................................................33
 

Summary................................................................................................................................... 35
 

Chapter 4. Results ..........................................................................................................................37
 

KQ 2: What Factors Influence the Use of Colorectal Cancer Screening?................................ 38
 

Patient Factors: Overview......................................................................................................39
 

Patient Factors: Three Nationally Representative Studies.....................................................40
 

Patient Factors: Overview of Additional Studies...................................................................49
 

Patient Factors: Followup after Positive FOBT.....................................................................90
 

Physician Factors Associated with CRC Screening...............................................................91
 

vii 
Patient-Provider Communication...........................................................................................99
 

Periodic Health Examinations..............................................................................................102
 

System Level Factors Associated With CRC Screening .....................................................103
 

Summary................................................................................................................................. 107
 

KQ 3: Which Strategies Are Effective In Increasing The Appropriate Use Of Colorectal 

Cancer Screening And Followup? .......................................................................................... 108
 

KQ 3 Overall Summary and Strength of Evidence..............................................................109
 

Patient Interventions ............................................................................................................112
 

KQ 4: Current and Projected Capacity to Deliver Colorectal Cancer Screening and 

Followup ................................................................................................................................. 136
 

KQ 4 Overall Summary and Strength of Evidence..............................................................137
 

National-Level Estimates of Current Capacity of Endoscopy Screening............................141
 

National Estimates of Ability to Meet Projected Demand for Endoscopy, by Different 

Demand Scenarios ...............................................................................................................144
 

KQ 5: Effective Approaches for Monitoring Use and Quality of Colorectal Cancer 

Screening................................................................................................................................. 149
 

Validity of Self-Report, Administrative Data, and Medical Record Review to 

Distinguishing Screening from Diagnostic Endoscopy Using an Algorithm for 

KQ 5 Overall Summary and Strength of Evidence..............................................................151
 

Measure CRC Screening Status...........................................................................................153
 

Administrative Data .............................................................................................................162
 

Evaluating Novel Ways to Combine Data Sources for CRC Screening Measurement.......163
 

Chapter 5. Discussion ..................................................................................................................167
 

Summary of Findings.............................................................................................................. 167
 

Implications of This Review................................................................................................174
 

Limitations of this Review...................................................................................................... 177
 

Limitations of the Evidence Base ........................................................................................177
 

Limitations of the Review....................................................................................................178
 

Future Research Directions..................................................................................................... 179
 

Conclusions............................................................................................................................. 181 

References....................................................................................................................................183 

List of Abbreviations ...................................................................................................................191
 

Glossary .......................................................................................................................................193 

Figures

Figure 1. Analytic framework for the appropriate use of colorectal cancer screening..................18 

Figure 2. Quorum tree/disposition of articles ................................................................................37
 

Tables 

Table 1. Inclusion/exclusion criteria..............................................................................................20 

Table 2. Strength of evidence grades and definitions....................................................................24 

Table 3. Trends in screening according to the National Health Interview Survey........................27 

Table 4. Trends in CRC screening according to the Behavioral Risk Factor Surveillance 

Survey ............................................................................................................................................27 

viii 
Table 5. Percentage of respondents 50 years of age or order who reported receiving a fecal 

occult blood test within 1 year and/or a lower endoscopy* within 10 years, by selected 

characteristics—BRFSS, United States, 2002, 2004, and 2006† ...................................................28 

Table 6. Overall findings from the three national studies for each category of patient 

Table 7. Adjusted CRC screening rates by key patient-level demographic characteristics, for 

Table 8. Adjusted CRC screening rates by patient-level variables of access to care for three 

Table 9. Adjusted CRC screening rates by patient-level personal health or risk factors for 

Table 21. Types of factors and descriptions of variables used in selected studies to examine 

Table 22. Studies of factors associated with followup after abnormal CRC screening results 

Table 24. Studies of the association between physician or practice connectedness with CRC 

Table 25. National studies of association between physician recommendations and CRC 

Table 26. Regional studies of the association of physician recommendation with CRC 

Table 28. Studies of association between periodic health examination (PHE) and CRC 

Table 36. Studies of small media: Educational materials and messages on increasing 

Table 37. Studies of small media: Decision aids on increasing colorectal cancer screening 

characteristics.................................................................................................................................40 

three national studies......................................................................................................................42 

national studies...............................................................................................................................45 

three national studies......................................................................................................................46 

Table 10. Studies of the association of age with CRC screening ..................................................50 

Table 11. Studies of the association of sex with CRC screening...................................................51 

Table 12. Studies examining the association between race and CRC screening...........................53 

Table 13. Studies of the association of Hispanic origin with CRC screening ...............................56 

Table 14. Studies of the association of Asian American origin with CRC screening ...................60 

Table 15. Studies of the association between acculturation and CRC screening ..........................64 

Table 16. Studies of the association of income with CRC screening ............................................70 

Table 17. Studies of insurance status as a predictor of CRC screening.........................................72 

Table 18. Studies of the association of access to care with CRC screening..................................75 

Table 19. Studies of the association of personal health/risk factors with CRC screening.............79 

Table 20. Studies of the association between psychosocial factors and CRC screening...............86 

the influence of psychosocial factors on CRC screening...............................................................89 

are received ....................................................................................................................................91 

Table 23. Studies of the association between physician characteristics and CRC screening........92 

screening ........................................................................................................................................93 

screening ........................................................................................................................................94 

screening ........................................................................................................................................97 

Table 27. Studies of the association of patient-provider communication and CRC screening......99 

screening ......................................................................................................................................103 

Table 29. Studies of the association between system level factors and CRC screening .............104 

Table 30. Effect of patient-level interventions on CRC screening rates......................................110 

Table 31. Effect of patient-level intervention on discussions with providers..............................111 

Table 32. Effect of provider-level interventions on CRC screening rates...................................111 

Table 33. Effect of system-level interventions on CRC screening rates .....................................112 

Table 34. Patient-level studies by category of intervention.........................................................113 

Table 35. Studies of patient reminders on increasing colorectal cancer screening rates.............115 

colorectal cancer screening rates .................................................................................................119 

rates..............................................................................................................................................122 

ix 
Table 38. Studies of group education on increasing CRC screening rates ..................................124 

Table 39. Studies of one-on-one interactions on increasing colorectal cancer screening 

Table 40. Studies of interventions to eliminate structural barriers on increasing colorectal 

Table 41. Study of an intervention to target provider behavior for increasing colorectal 

Table 42. Studies of interventions to target the system level for increasing colorectal cancer 

Table 43. Strength of evidence for the current and projected capacity to deliver CRC 

Table 47. National estimates of ability of current volume or additional available capacity of 

flexible sigmoidoscopy or colonoscopy to meet projected demand for endoscopy, by 

Table 48. Characteristics of public health monitoring systems that contribute to 

Table 49. Strength of evidence for approaches to monitoring effectiveness of CRC 

Table 50. Assessing validity of CRC screening measures: Comparing prevalence of CRC 

Table 51. Assessing validity of CRC screening measures: Concordance among data sources 

Table 52. Comparison of classification of diagnostic versus screening procedure using an 

Table 56. Suggested research agenda to improve the appropriate use and quality of CRC 

rates..............................................................................................................................................126 

cancer screening rates ..................................................................................................................128 

cancer screening or followup rates ..............................................................................................131 

screening rates..............................................................................................................................133 

screening ......................................................................................................................................138 

Table 44. Overview of results of capacity studies .......................................................................141 

Table 45. National estimates of current volume of endoscopy screening ...................................142 

Table 46. National estimates of additional available capacity of endoscopy screening..............144 

different demand scenarios ..........................................................................................................145 

effectiveness.................................................................................................................................150 

screening use and quality.............................................................................................................152 

screening rates by various data sources .......................................................................................158 

for CRC screening measures........................................................................................................158 

algorithm for administrative data.................................................................................................163 

Table 53. Evaluating novel ways to combine data sources for CRC screening measurement ....165 

Table 54. Summary of the evidence and strength of evidence grades by key question ..............168 

Table 55. Features of an ideal monitoring system for CRC screening use and quality...............174 

screening (priority areas in bold font)..........................................................................................179 

Appendixes 

Appendix A: Exact Search Strings ............................................................................................. A-1 

Appendix B: Sample Data Abstraction Forms.............................................................................B-1 

Appendix C: Evidence Tables .....................................................................................................C-1 

Appendix D: List of Excluded Studies ....................................................................................... D-1 

Appendix E: Colorectal Cancer Screening Technical Expert Panel (TEP) Members .................E-1 

Appendix F: Poor Quality Studies ...............................................................................................F-1 

Appendix G: Supplemental Information for KQ 4 ..................................................................... G-1 

Appendixes and Evidence Tables for this report are provided electronically at 

http://www.ahrq.gov/downloads/pub/evidence/pdf/crcuse/crcuse.pdf. 

x 
xi
 
Executive Summary 

Introduction 

Periodic screening of people at average risk for colorectal cancer (CRC) is recommended by 

three important national guideline groups, the United States Preventive Services Task Force 

(USPSTF), the American Cancer Society (ACS), and the U.S. Multi-Society Task Force on 

Colorectal Cancer (MSTF), as well as multiple professional societies. For CRC screening to 

contribute to a reduction in CRC mortality without unreasonable harms and costs, however, it 

must be offered to people who have a reasonable probability of net benefit, and it must be 

conducted effectively and efficiently. These issues of use and quality are especially salient for 

CRC screening because it is in some ways more complex (e.g., variation in timing and types of 

tests, invasiveness of most tests) than other screening programs. Underuse of CRC screening has 

been a clear problem for some years; evidence is now growing that overuse (i.e., screening 

people with little potential for net benefit) and misuse (i.e., conducting screening in ways that 

reduce net benefit) may also be important problems. 

The RTI International-University of North Carolina Evidence-based Practice Center (RTIUNC EPC) prepared this report, under the auspices of the Agency for Healthcare Research and 

Quality, for the National Institutes of Health (NIH) State-of-the-Science Conference on 

Enhancing Use and Quality of Colorectal Cancer Screening, which is scheduled for February 

2010. This report is a systematic review of evidence about the use and quality of screening for 

CRC focusing on four primary key questions (KQs). It also includes an initial background 

section (KQ 1) on trends and the current situation of use and quality, and it presents a concluding 

discussion on needed research (KQ 6). The specific KQs of interest were as follows: 

KQ 1. What are the recent trends in the use and quality of CRC screening? 

KQ 2. What factors influence the use of CRC screening? 

KQ 3. Which strategies are effective in increasing the appropriate use of CRC screening and 

followup? 

KQ 4. What are the current and projected capacities to deliver CRC screening and followup 

at the population level? 

KQ 5. What are the effective approaches for monitoring the use and quality of CRC 

screening?
 

KQ 6. What research is needed to make the most progress and have the greatest public 

health impact in promoting the appropriate use of CRC screening? 

Methods 

We searched MEDLINE®, the Cochrane Library, and the Cochrane Central Trials Registry 

for studies published in English from January 1998 through September 2009. We searched data 

sources using Medical Subject Heading (MeSH) terms when available or key words when 

appropriate. MeSH terms for our searches included colorectal neoplasms, colonoscopy, 

sigmoidoscopes (including flexible sigmoidoscopy [FS]); major headings included mass 

screening; and key terms included stool test, fecal occult blood test (FOBT), and DNA stool). 

1 
We used standard EPC methods of dual review of abstracts, full text articles, data abstraction 

for evidence tables, rating quality of articles, and grading strength of evidence. Specifically, we 

rated the internal validity of studies as good, fair, or poor. We used the AHRQ EPC program’s 

approach to grading strength of evidence as high, moderate, low, or insufficient for KQs 3, 4, 

and 5. We resolved disagreements by consensus. 

KQ 1: Background on Recent Trends in Use and Quality of CRC 

Screening 

This section summarizes trends in the use of CRC screening tests, CRC screening 

discussions, and the quality of CRC screening. In some cases, data were insufficient to determine 

trends, but we present current status where possible. 

Underuse of both CRC screening and patient-physician discussions of CRC screening is 

clear. Self-reported screening rates by national surveys, which are likely overestimates of actual 

screening, have increased from less than 25 percent in the late 1980s to about 50 percent to 60 

percent in 2005 to 2006; an even smaller percentage of people had had a discussion about CRC 

screening with their primary care physician. The increased screening can be attributed entirely to 

an increase in the use of screening colonoscopy; screening with FOBT and sigmoidoscopy 

declined over this period. We found no data on the trends of use or quality of fecal 

immunochemical test, fecal DNA testing, or computed tomographic colonoscopy. 

Few health care systems have developed monitoring systems to provide physicians with 

feedback on CRC screening rates, nor have they provided incentives to physicians for improving 

screening. The health care system of the Veterans Health Administration (VA), which relies 

more on FOBT than other modalities for screening and which has developed monitoring and 

incentive systems, has screening rates above 75 percent. 

At the same time as the underuse documented above, screening can be overused when people 

who are unlikely to benefit are screened: for example, people older than 85 years and/or people 

with severe comorbidities. Surveillance colonoscopy and, probably, polypectomy for diminutive 

polyps less than 5mm where benefit is uncertain but increased risk is clear, may also be overused 

though research on this issue is still needed (i.e., the extent to which removal of small polyps is a 

greater or lesser harm to the patient compared to ignoring the polyps). 

Finally, problems of misuse, screening in such a way as to reduce benefits and/or increase 

harms, are also clear. These include use of in-office rather than home FOBT; nonreturn of FOBT 

cards; lack of adequate followup of positive FOBT results; colonoscopy that does not reach the 

cecum, has too rapid withdrawal time, that misses important lesions, and colonoscopy with high 

adverse event rates. 

Results 

 Our initial searches of electronic databases, along with handsearches and an updated search in 

October 2009 produced 3,029 unduplicated records. Ultimately, for the four main questions, we 

included the following numbers of articles that were rated either good or fair quality: 72 studies 

addressing KQ 2, 21 addressing KQ 3, 12 addressing KQ 4, and 8 addressing KQ 5. We 

excluded studies rated poor quality from our analyses. 

2 
KQ 2: Factors Influencing Colorectal Cancer Screening 

We categorized studies examining factors associated with the use of CRC screening tests into 

five domains: patient factors, physician factors (including physician characteristics, physicianpatient connectedness, and physician recommendations about screening), patient-physician 

communication factors, the periodic health examination, and system factors. We further 

categorized the patient factors into four groups: patient demographics, access to care, personal 

health or risk factors, and psychosocial factors. 

All studies focused on factors associated with underuse of CRC screening. None focused on 

factors associated with underuse of CRC discussions or on factors associated with overuse or 

misuse of CRC screening. 

Factors consistently and significantly associated with reduced CRC screening include 

•	 low household income, 

•	 no health insurance, 

•	 being Hispanic or Asian, 

•	 not being acculturated into the United States, 

•	 limited access to care (i.e., lack of a regular source of primary care and no visits in 

previous year to provider), and 

•	 no physician recommendation to be screened. 

Factors positively associated with CRC screening include having private insurance, being 

non-Hispanic white, having a higher education level, participating in regular screenings for other 

cancers, having a family history of CRC or personal history of another cancer, having regular 

access to care, having effective patient-provider communication, and having a physician 

recommendation for screening. We found two studies that focused on patient factors that seem to 

influence followup rates after receipt of an abnormal result. We found one study each that 

examined the association between screening and specific physician characteristics, patientphysician connectedness, and periodic health examinations. Thus, we did not draw conclusions 

about these relationships because the evidence was insufficient. Studies on system level factors 

that might influence CRC screening did not consistently measure the same variables but seem to 

support counseling by nonclinicians, reminder systems, and assisting patients to keep 

appointments. 

KQ 3: Effective Strategies for Increasing Appropriate Use of 

Colorectal Cancer Screening 

We first categorized studies into three intervention targets: patients, physicians, and health 

care systems. Following similar categories recently used to develop recommendations for the 

Task Force on Community Preventive Services (TFCPS), we further divided the patient-level 

interventions into five categories: (1) patient reminders; (2) small media (with and without 

decision aids); (3) group education; (4) one-on-one interactions; and (5) eliminating structural 

barriers. All studies of interventions focused on reducing underuse of CRC screening and/or 

followup after receiving a positive FOBT. We found one study that examined an intervention to 

increase patient-physician discussions about CRC screening. No study tested an intervention to 

reduce overuse or misuse of CRC screening. 

3 
Interventions that provided patient reminders led to small to moderate increases in CRC 

screening, with high strength of evidence (5.0 to 15.0 percentage point increase). Studies of 

small media (educational print or video messages) to increase CRC screening showed no benefit, 

with high strength of evidence. Evidence concerning decision aids to increase screening was 

mixed. With two of three studies showing benefit, some types of decision aids may be effective 

for increasing screening (14.2 to 23.0 percentage point increase in screening rates reported in the 

two positive studies; 3.0 percentage point increase in the one negative study), although overall 

strength of evidence was low. Evidence was also mixed (i.e., low strength of evidence) 

concerning the effect of group education, with one study showing a negative effect on screening 

and another finding a small positive effect. One-on-one interactions, especially with intensive 

contact with patients by a nurse, a health educator, or on the phone, increased screening rates, 

sometimes to a large degree, with percentage point increases such as 14.6 percentage points in 

FOBT completion, 20.9 percentage points of any CRC test, and 41.9 percentage points in FOBT 

completion. Strength of evidence for this type of intervention was high. Interventions that 

eliminated structural barriers, such as by providing FOBT tests to use at home or providing 

access to individuals who can help to address barriers, also increased screening rates, with high 

strength of evidence (absolute rate change from 14.6 to 41.9 percentage points). 

Two studies of physician-targeted reminder interventions found either no effect or a very 

small effect on appropriate screening, with low strength of evidence. More evidence was 

available for evaluating various system-level interventions (e.g., implemented changes to 

improve referral of patients for screening or identified a person such as a patient navigator or 

someone in a similar role (i.e., Prevention Care Manager or PCM) to help patients navigate the 

health care system). These studies found consistently positive effects on screening (7.0 to 28.2 

percentage point difference in screening rates compared to control groups), with high strength of 

evidence. 

KQ 4: Capacity to Deliver Colorectal Cancer Screening and Followup 

Initially, we examined three aspects of this issue: current capacity to conduct CRC screening 

(six studies in seven articles), projected capacity (five studies), and ability to meet projected 

demand (i.e., nation’s ability to meet the projected demand under various scenarios, such as 

screening the entire eligible U.S. population with a specific test). Several modeling studies, using 

various assumptions, addressed these issues. 

These modeling studies found that if the United States were to adopt a colonoscopy-only 

approach to CRC screening and if everyone were to agree to be screened in this way, 

colonoscopy capacity would need to be substantially increased to do the “catch-up” screening 

required to screen people who have not been screened and to continue to screen in a steady state 

for all eligible people. The strength of evidence for all the data and estimates from these studies 

is low. 

KQ 5: Effective Approaches for Monitoring CRC Use and Quality 

We found no studies that directly answered the question of how CRC screening use and 

quality have been effectively monitored and tracked in the past decade. Included studies 

addressed only one specific component of monitoring, namely data quality; we found no studies 

that described or compared other monitoring system attributes. Overall in our review we found 

that some national surveys (e.g., the National Health Interview Survey [NHIS], the Behavioral 

4 
Risk Factor Surveillance System [BRFSS]) monitor self-reported CRC screening by the U.S. 

population. Current national registries are inadequate to monitor accurately the CRC screening 

rates of medical practices, and few practices (with the exception of the VA system and the 

National Committee on Quality Assurance Healthcare Effectiveness Data and Information Set 

[HEDIS]) monitor their own CRC screening rates or the quality of CRC screening. No current 

national registries monitor either CRC discussions or overuse or misuse (including adverse 

events) of CRC screening. Registries for conditions other than CRC may provide some models 

for CRC screening. 

Discussion 

Although recent trends have shown a gradual increase in CRC screening, these increases still 

leave levels of CRC screening considerably below levels for breast cancer screening. Some 

differences between the rates for CRC screening and breast cancer screening may occur because 

of the nature of CRC screening, with several options for screening strategies, each with its own 

set of preparation and completion difficulties for the patient. The implications of this review are 

related primarily to the findings specific to the interventions tested to increase screening, and to 

three cross-cutting themes that underlie our findings: access to CRC screening; communication 

about CRC screening; and the organization of CRC screening. 

Interventions to Improve Screening 

The interventions reviewed in KQ 3 deserve further comment. Although we found high 

strength of evidence and positive effects for patient reminders, one-on-one interactions, 

eliminating structural barriers to screening, and system-level interventions, whether any specific 

set of interventions would effectively increase screening rates across the country remains 

unclear. First, whether we have the ability to implement these interventions on a broad scale 

within medical practices, and for the general population, is uncertain. To implement and 

maintain these interventions properly, an effective monitoring and feedback system (KQ 5) is 

needed. These systems are not in place in most primary care practices. Second, overcoming the 

focus in primary care practices on nonpreventive care, and overcoming the time and cost barriers 

to implementing and maintaining these types of screening systems within busy primary care 

practices, both present uncertainties. Partly because of the lack of positive incentives and the 

required time and effort from primary care practices, the durability of interventions that initially 

seem successful is uncertain. Finally, the cost effectiveness of the sometimes intensive 

interventions to gain disproportionately small increases in screening is also unknown. Until these 

more fundamental issues are dealt with, widespread implementation of any interventions may not 

have a large, sustained effect at reasonable costs (including time and effort of the patient, the 

physician, and the medical practice). 

Access to CRC Screening 

A critical underlying issue in this literature is access to care, a necessary precursor to access 

to CRC screening. Among the most striking findings from our review of factors associated with 

lower rates of CRC screening (KQ 2) is that people without health insurance, people with no 

source of usual care, people with no recent physician visits, and people with lower income status 

have quite low CRC screening rates. Improved communication can only be effective for people 

5 
who are connected (KQ 2) to a primary care provider. For CRC screening rates to improve 

dramatically, providing more standard access to this care for people who will benefit the most is 

essential. 

Communication About CRC Screening 

One positive finding of this report is the overall importance of communication specific to 

CRC screening between medical staff and patients in improving appropriate CRC screening (i.e., 

reducing underuse, overuse, and misuse). CRC screening requires a great deal of patient 

understanding and effort (e.g., knowing which tests to take and when, and how to get them 

done). Communicating such information to patients and guiding them in making decisions 

specific to their medical and family history all take time. To make appropriate decisions about 

individually optimal screening, to carry out the preparation and follow-through correctly, and to 

obtain screening at recommended intervals all require patient knowledge, motivation, and 

assistance from medical personnel. When few CRC discussions take place (KQ 1), when many 

eligible patients do not know that they should be screened (KQ 2), when medical personnel make 

few recommendations for screening (KQ 2), when many people do not receive periodic health 

exams [during which time might be devoted to discussions of CRC screening (KQ 2)], and when 

few intensive one-on-one or system level interventions exist, including those to eliminate 

barriers, to assist patients to decide, prepare, and follow-through (KQ 3), suboptimal screening 

rates should not be surprising. 

Organization of CRC Screening and Monitoring 

CRC screening in the United States requires the involvement of primary care physicians, 

most of whom receive no regular feedback on their CRC screening rates, as might occur in the 

VA or other integrated health care system. Few medical practices involve nonphysician office 

staff in discussing CRC screening with patients; few reach out to patients who have not been 

screened or who miss screening appointments. As suggested by the VA’s success with CRC 

screening (KQ 1), by the association of use of nonphysician staff with higher CRC screening 

rates (KQ 2), and by randomized controlled trials (RCTs) of organizational change (KQ 3) to 

improve screening, organizational change supported by monitoring and feedback systems (KQ 5) 

could have a positive effect on screening. Nonetheless, drawing conclusions on how to reduce 

overuse and misuse will always be difficult without adequate monitoring of these outcomes. 

A second important aspect of organization is external to the primary care practice, and 

involves coordination of various parts of the health care system involved in CRC screening. 

Because these parts of the health care system are often fragmented, barriers are set up that 

patients must navigate to complete screening. These same barriers work against monitoring the 

progress of patients as they move through the system, and providing assistance to those who are 

not able to surmount the barriers. Finally, these barriers create problems for providing consistent 

and timely information to patients, and for establishing systems to reduce overuse and misuse. 

KQ 6: Future Research Directions 

The priority for research should be RCTs of interventions to implement appropriate CRC 

screening (i.e., minimizing underuse, overuse, and/or misuse) and monitoring, which is then 

linked to improvement initiatives. In our review, we became aware of multiple studies of the 

6 
operating characteristics of potential new CRC tests. Although improving screening tests is a 

reasonable research agenda (especially in finding ways to reduce the need for the most invasive 

and expensive tests), a greater balance with research could help find ways to implement 

screening programs that we already know are effective. To focus research primarily on 

developing newer screening tests without placing higher priority on implementation of the 

effective existing tests leaves people with inadequate screening. 

Our review suggests that three steps are required for achieving higher rates of appropriate 

screening: (1) increasing patient access to care; (2) improving effective communication about 

screening and screening options between trained educators (physicians or nonphysicians) and 

patients; and (3) simplifying and coordinating organizational structures to better facilitate 

patients in completing screening. At least as important as developing newer screening tests is 

research to test interventions to improve access, communication, and organization of health. 

Not only must the organizational and system features needed to increase screening be 

understood, but research also needs to consider the interaction of system features with 

characteristics of the population. Several studies testing interventions (KQ3) were implemented 

within clinic settings, limiting the generalizability of the findings. More needs to be understood 

about how interventions work in increasing screening among those receiving services through 

different settings. Since studies show that people who have access to a regular source of care are 

more likely to be screened (KQ2), research should focus more on those without this facilitator. In 

addition, access, communication, and organizational requirements to increase appropriate 

screening will most likely differ depending on the population involved. The most efficient and 

cost-effective approaches to increase appropriate screening will probably include some tailoring 

of the intervention to these and other specific populations. 

After determination of the effectiveness and cost effectiveness of various interventions, 

pragmatic trials focused on implementation of successful strategies within different types of 

health care systems and populations are needed. Different intensities of interventions, and even 

wholly different interventions, will likely be needed for different populations. Interventions 

should be targeted at the specific steps that are problems for specific populations (e.g., those who 

speak other languages than English at home could likely benefit from more basic interventions to 

increase awareness and discussions, whereas those who are already obtaining screening on an 

irregular basis may benefit most from patient reminders). 

Further, we also need continued research into measuring current volume and projected 

demand for screening strategies. Finally, we found little evidence that adequate monitoring 

systems that assess the full spectrum of appropriate CRC screening (including overuse, underuse, 

and misuse) are in widespread use, and are being used to improve screening. Such monitoring 

systems are critically important for continued improvement of CRC screening, especially for 

reduction of overuse and misuse. There is a large and important research agenda in developing 

and testing interventions to increase discussions of CRC screening, and to reduce overuse and 

misuse. 

Throughout this review, accurately describing results for the outcome of CRC screening has 

been a major challenge because of the inconsistencies in how it has been measured and/or 

operationalized. We see a need to develop standard measures for assessing the outcomes (and 

also for assessing factors associated with screening). While efforts have been completed in the 

past to standardize related measures for how CRC screening is to be assessed and then to develop 

valid measures, these measures have not been consistently used in all national surveys or studies, 

making it difficult to accurately assess current screening rates. Better application of these 

7 
existing measures would greatly improve the quality of the findings from studies to be done in 

the future, thereby expanding our understanding of what factors influence CRC screening that 

can actually be addressed through interventions and policy development. 

This need for standard measures and mechanisms for collecting the data directly relates to the 

findings for KQ 5, in that we found no studies that directly answered the question of how CRC 

screening use and quality have been effectively monitored and tracked in the past decade. 

Without more information that is systematically collected through provider practices, hospitals, 

clinics, and other primary care organizations, our understanding of CRC screening will continue 

to be less than optimal. 

Conclusions 

Our review suggests that the United States is yet some distance from fully realizing the 

promise of appropriate and high-quality CRC screening. Problems of underuse, overuse, and 

misuse are not being adequately addressed at present. By focusing our research effort on the 

issues that matter most—access to screening, communication between patient and medical staff, 

the organization of care—and by further researching how to implement effective and costeffective strategies into actual primary care practice, we will have the greatest opportunity to 

reduce the burden of suffering of CRC for the people of the United States. 

8 
Evidence Report 

Chapter 1. Introduction 

Periodic screening of people at average risk for colorectal cancer (CRC) is recommended by 

three important national guideline groups, the United States Preventive Services Task Force 

(USPSTF), the American Cancer Society (ACS), and the U.S. Multi-Society Task Force on 

Colorectal Cancer (MSTF),3-4 as well as multiple professional societies. For CRC screening to 

contribute to a reduction in CRC mortality without unreasonable harms and costs, however, it 

must be offered to people who have a reasonable probability of net benefit, and it must be 

conducted in an effective and efficient manner. These issues of use and quality are especially 

salient for CRC screening because it is in some ways more complex than other screening 

programs. We understand “quality” to refer to “underuse,” “overuse,” and “misuse”5 rather than 

simply test performance. Underuse of CRC screening has been a clear problem for some years; 

evidence is now growing that overuse (i.e., screening people with little potential for net benefit) 

and misuse (i.e., conducting screening in ways that reduce net benefit) may also be important 

problems. 

This report is a systematic review of four key questions (KQs) concerning the use and quality 

of screening for CRC. As part of the first KQ, a background section on trends and the current 

situation of use and quality are presented. Literature was not systematically reviewed for this KQ 

but are instead summarized to provide the reader with a sense of the current status of trends in 

CRC testing. The purpose of the remaining five KQs is to inform recommendations for 

improving the use and quality of CRC screening. To achieve this goal, we provide information 

about factors associated with the use of CRC screening (KQ 2), effective strategies for increasing 

the appropriate use of CRC screening and followup (KQ 3), the current and projected capacity of 

the US health care system to deliver tests (especially colonoscopy) for the population needing 

screening (KQ 4), and approaches for monitoring the use and quality of CRC screening (KQ 5). 

We then conclude the review in Chapter 5 with a discussion that includes recommendations for 

research needed to make progress and have greatest public health impact in promoting the 

appropriate use of CRC screening (KQ 6). The RTI International-University of North Carolina 

Evidence-based Practice Center (RTI-UNC EPC) prepared this report for the National Institutes 

of Health (NIH) State-of-the-Science Conference on Enhancing Use and Quality of Colorectal 

Cancer Screening, which is scheduled for February 2010. 

Development of Evidence and Recommendations for CRC 

Screening 

Several screening tests for CRC are in current use, including guaiac-based fecal occult blood 

test (gFOBT, which can be either high or low sensitivity), fecal immunochemical test (FIT), 

flexible sigmoidoscopy (FS), and colonoscopy. Two other tests have been used in the past but 

are less used today: digital rectal examination and double contrast barium enema (DCBE). Two 

newer tests have been proposed but are not in widespread use: fecal DNA and computed 

tomographic colonography (CTC).6 This report will focus on the current and newer tests. 

Since the early 1990s, four randomized controlled trials (RCTs) of screening with gFOBT7-10 

have found a relative reduction of 16 percent to 33 percent in CRC mortality (absolute risk 

reduction = 2.9 deaths/1,000 over 13 years in the U.S. trial), first appearing 5 to 7 years after 

start of screening. Although the USPSTF found insufficient evidence to recommend screening in 

1989,11 before the RCTs had reported, it recommended screening with gFOBT or FS (supported 

. 

11 
by a good-quality case-control study) in 1996,12 after several RCTs were published. The 1996 

USPSTF recommendation, however, found insufficient evidence to recommend screening with 

colonoscopy, noting the lack of RCT evidence to determine the magnitude of benefit. In 2002, 

the USPSTF broadened its recommendation to include screening with any of several tests, 

including gFOBT, FS, and colonoscopy. The recommendation for colonoscopy was based on 

extrapolation of benefits from studies of FOBT and FS.13-15 

In 2008, the USPSTF updated its recommendation again, recommending screening with any 

of several tests, including gFOBT, FIT, FS, and colonoscopy. It recommended that adults ages 

76 to 85 not be screened routinely (i.e., screening should be determined by modeling a history of 

sufficient screening up until that point) and that adults ages 85 years and older not be screened at 

all. It found insufficient evidence to make any recommendation concerning screening with fecal 

DNA or CTC.3 

The USPSTF placed emphasis on the need for discussion between providers and individual 

patients to determine the optimal screening strategy. As noted in the 2002 recommendation 

statement: 

The choice of specific screening strategy should be based on patient preferences, 

medical contraindications, patient adherence, and available resources for testing and 

follow-up. Clinicians should talk to patients about the benefits and potential harms 

associated with each option before selecting a screening strategy.13 

The MSTF has issued three sets of guidelines over the past 12 years (1997, 2003, and 2008) 

on screening for CRC; they were joined in the 2008 guideline by the American Cancer Society 

(ACS) (which had developed its own guidelines over previous years) and the American College 

of Radiology (ACR). The 1997 guideline recommended screening using one of five options: 

annual FOBT, FS every 5 years, annual FOBT and FS every 5 years combined, double-contrast 

barium enema every 5 to 10 years, and colonoscopy every 10 years.16 The 2003 recommendation 

repeated the same options, noting that “these guidelines offer screening options and encourage 

the physician and patient to decide together which is the best approach for them.”17 The 2008 

recommendation suggested the same tests but added CTC and fecal DNA testing.4

 The 2008 

guideline departed from the previous MSTF recommendations in that it separated screening tests 

into those that primarily detect CRC (gFOBT, FIT, fecal DNA) and those that detect both CRC 

and colonic polyps (FS, colonoscopy, CTC, barium enema). It recommended a test from the 

latter group most strongly but also approved screening with a test from the former group if the 

patient refused a test that detects both CRC and polyps. The guideline states “When possible, 

clinicians should make patients aware of the full range of screening options, but at a minimum 

they should be prepared to offer patients a choice between a screening test that primarily is 

effective at early cancer detection and a screening test that that is effective at both early cancer 

detection and removal of polyps”. (p. 1570)4

 Because of the changes and, often, the 

inconsistencies in the national guidelines, and because of such issues as patient preferences, 

medical contraindications, patient adherence, and available resources,13 a number of factors can 

affect whether or not a patient is screened. These factors are described and literature presented 

under KQ 2 in Chapter 4. 

Four issues emerge from this brief review above. First, although only gFOBT has been tested 

in full RCTs of CRC screening, guideline groups have determined that other tests that find early 

CRC would also be effective in reducing CRC mortality. This allows a range of screening 

options, each with its own set of potential benefits and harms. 

. 

12 
Second, this range of options has presented problems in making recommendations, making 

screening for CRC more complex in some ways than screening for such conditions as breast 

cancer where fewer tests (mammography, clinical breast examination) are recommended. The 

solution proposed by both the USPSTF and the MSTF has been discussion with patients to make 

individualized screening decisions. The variation in potential benefits and harms of the range of 

options, however, makes it unlikely that brief discussions can achieve a truly informed decision. 

Longer discussions to fully address all related issues are problematic because of the limited time 

already afforded to the physician to address preventive care during a specific medical 

appointment. 

Third, experts disagree about whether tests that detect polyps in addition to CRC (so-called 

“structural tests,” such as colonoscopy) should be preferred over tests that primarily detect CRC 

(“nonstructural tests” such as FOBT and FIT, which are among the tests recommended by the 

USPSTF). Most of the mortality reduction in the RCTs of gFOBT (over 10 to 15 years of 

followup) has likely come from detection of early CRC rather than removal of polyps, although 

polypectomy has been shown to reduce the incidence of CRC by about 20 percent over 18 years 

of followup.18 In addition, the primary structural test (colonoscopy) carries greater potential harm 

and cost than non-structural tests. Thus, the evidence is not clear that the net benefits (benefits 

minus harms) of structural tests are greater than those of non-structural tests. 

Fourth, the USPSTF recommends stopping routine CRC screening after age 75 (and all CRC 

screening after age 85). The MSTF acknowledges that a different screening recommendation 

may be appropriate for older people, but they delayed comment in the current guideline.4 

Implementation of Guidelines: Use and Quality 

Although a substantial range of effective options exists, CRC screening cannot optimally 

reduce CRC mortality without unreasonable harms and costs unless two conditions are met: 

(1) screening is used by a large percentage of eligible people and (2) screening minimizes 

problems of quality such that patients are being screened appropriately, according to current 

national guidelines (i.e., underuse, overuse, and misuse are addressed). By underuse of CRC 

screening we mean that people who would likely derive a net benefit (in which benefits exceed 

risks or harms by a meaningful amount) are not screened at all or not screened at an appropriate 

frequency. Underuse is a common issue at the beginning of screening programs. Mammography 

screening for breast cancer, for example, took some years to become widespread; the 2005 

Behavioral Risk Factor Surveillance System found that 74.6 percent of women ages 40 years and 

older reported having had a mammogram within the previous 2 years.19 An important question is 

whether the greater complexity of CRC screening (e.g., variety of tests, timing of each, 

benefits/harms of each, invasiveness of most) will result in a lower percentage of eligible people 

being screened, a concern of special importance for disadvantaged populations where underuse is 

often most severe. In addition to the underuse of CRC screening tests, there is a parallel underuse 

of discussions between patients and clinicians about CRC screening, as recommended by both 

major guideline groups. 

By overuse of CRC screening we mean the screening of people (or the use of screening 

techniques) with a low probability of net benefit. Among the common overuse issues are 

screening people with severe comorbidities and screening people over age 85 (as both groups 

would be unlikely on a population level to live long enough to benefit from screening). Another 

overuse concern is overly frequent surveillance colonoscopy after a previous polypectomy; the 

. 

13 
natural history of colonic polyps is that only a small percentage progress to invasive cancer, and 

this progression takes many years. Thus, the frequency of surveillance should be determined by 

the probability of a patient developing a lesion that needs to be detected to extend life. Finally, 

although little literature exists on this issue, another potential problem of overuse of polypectomy 

may involve small polyps less than 5 mm in size. Because the current colonoscopy policy is to 

remove all polyps regardless of size, removal of small, low-risk polyps may yield little benefit. 

Yet evidence is clear that any polypectomy increases the risk of such adverse events as colonic 

bleeding.20 

By misuse of CRC screening we mean conducting screening in ways that reduce net benefit 

for the people being screened. For example, misuse occurs when positive FOBT screening tests 

are not followed up within a reasonable time by full colon examination (such as colonoscopy). 

Another misuse problem is high rates of adverse events (e.g., colonic bleeding) from 

colonoscopy. These adverse events occur more frequently in people who have biopsies or 

polypectomies and in older people.20 Colonoscopy that misses clinically important lesions is also 

an example of misuse. This can result from such factors as lack of full insertion of the 

colonoscope, too rapid withdrawal time, poor bowel preparation, or lack of skill of the 

colonoscopist. 

Scope of this Report 

In Chapter 2, we begin by presenting an overview of the methods used to address each KQ, 

including a description of the analytical framework used to guide our review. It is in Chapter 2 

that we present the inclusion and exclusion criteria used for developing the systematic review. 

We note that although this report draws on the literature of the effectiveness of CRC screening, it 

does not review specific benefits and harms of screening. The presented literature notes gaps in 

the evidence base at appropriate times and states uncertainties where they exist. It does not, for 

example, examine the evidence of the operating characteristics of various CRC screening tests. 

The first KQ, “what are the recent trends in the use and quality of colorectal cancer 

screening?” is presented in Chapter 3 and provides background information relative to patterns 

of use of CRC screening tests. The other four KQs entailed formal systematic reviews of the 

literature and results are presented in Chapter 4. The following are the four KQs for which we 

systematically reviewed available evidence: 

•	 KQ 2: What factors influence the use of colorectal cancer screening? 

o There are two ways that this information may assist policymakers in improving the use 

and quality of CRC screening. One way is by uncovering modifiable factors that could 

be targeted in a future intervention. Another way is to show that problems in use and 

quality are more prevalent in one population than another. This would allow 

interventions to be targeted to specific population groups. 

•	 KQ 3: Which strategies are effective in increasing the appropriate use of colorectal 

cancer screening and followup? 

o There are many types of interventions that could, and have been, considered to 

improve problems in use and quality of CRC screening. Policymakers need to know 

whether certain ones have been shown to be effective enough to implement 

immediately, and which ones are most promising for future research. 

. 

14 
•	 KQ 4: What are the current and projected capacities to deliver colorectal cancer screening 

and surveillance at the population level? 

o The primary issue here is whether screening capacity is adequate to meet expected 

demands, assuming that screening rates increase to optimal levels. This is a special 

concern with colonoscopy, which is used for both screening and surveillance. If 

colonoscopy capacity is inadequate for a screening policy that prioritizes structural 

tests, then other approaches will need to be considered. 

•	 KQ 5: What are the effective approaches for monitoring the use and quality of colorectal 

cancer screening? 

o	 To improve any health care program, one must be able to measure the expected 

outcome to determine when various interventions are achieving their intended result. 

Thus, we need to know whether we have systems in place to monitor adequately 

appropriate use and quality. 

The final KQ, KQ 6, addressed “what research is needed to make the most progress and have the 

greatest public health impact in promoting the appropriate use of colorectal cancer screening?” 

and is incorporated into the discussion in Chapter 5. 

Organization of this Report 

The remainder of this report describes our methods to review and synthesize the literature 

(Chapter 2) and then summarizes the background specific to trends in use and quality of 

screening (KQ 1 in Chapter 3) and presents our systematic review results for KQ 2-5 (Chapter 

4). In the discussion (Chapter 5), we summarize the findings and discuss the implications for 

practice and further research. A complete list of references is located immediately following the 

discussion chapter, along with a glossary of terms and a list of abbreviations used throughout this 

report. This report also contains the following appendices: Appendix A contains the exact search 

strings we used; Appendix B is all of the data abstraction forms used; Appendix C are our 

evidence tables; Appendix D is a list of our excluded studies; Appendix E lists the members of 

our Technical Expert Panel as well as our Peer Reviewers of a draft report; Appendix F lists our 

poor quality studies; and Appendix G contains supplemental information for KQ 4. 

. 

15 

Chapter 2. Methods 

In this chapter, we document the procedures that the RTI International–University of North 

Carolina Evidence-based Practice Center (RTI–UNC EPC) used to develop this comprehensive 

evidence report on use and quality of screening tests for colorectal cancer (CRC). To provide a 

framework for the review, we first present the key questions and their underlying analytic 

framework. We then describe our inclusion and exclusion criteria, search and retrieval process, 

and methods of abstracting relevant information from the eligible articles to generate evidence 

tables. We also discuss our criteria for rating the quality of individual articles and for grading the 

strength of the evidence as a whole. 

Technical Expert Panel (TEP) 

In designing the study questions and methodology at the outset of this report, we consulted 

several technical and content experts, seeking broad expertise and perspectives. We identified 

five technical experts, in addition to the chair for the National Institutes of Health State-of-theScience Conference on Enhancing Use and Quality of Colorectal Cancer Screening, for a total of 

six members (Appendix E).*

 The TEP provided assistance throughout the project and contributed 

to the Agency for Healthcare Research and Quality (AHRQ’s) broader goals of (1) creating and 

maintaining science partnerships as well as public-private partnerships and (2) meeting the needs 

of an array of potential customers and users of its products. Thus, the TEP was both an additional 

resource and a sounding board during the project. 

Divergent and conflicting opinions are common; we perceive them as healthy scientific 

discourse that contributes to a thoughtful, relevant systematic review. Nonetheless, in the end, 

study questions, design, and/or methodologic approaches do not necessarily represent the views 

of individual technical and content experts. 

To ensure robust, scientifically relevant work, we called on the TEP to provide reactions to 

work in progress and advice on substantive issues or possibly overlooked areas of research. 

Specifically, TEP members participated in conference calls and discussions through e-mail to: 

•	 refine the analytic framework at the beginning of the project; 

•	 discuss the preliminary assessment of the literature, including inclusion/exclusion 

criteria; and
 

•	 provide input on the information and categories included in evidence tables. 

Because of their extensive knowledge of the literature, including numerous articles authored 

by TEP members themselves, and their active involvement in the field, we also asked TEP 

members to participate in the external peer review of the draft report. 

Key Questions and Analytic Framework 

Based on the key questions (KQs) described in Chapter 1, we developed an analytic 

framework to guide our systematic review. To recap, the KQs are as follows: 

*

 Appendixes and evidence tables cited in this report are available at 

http://www.ahrq.gov/downloads/pub/evidence/pdf/crcuse/crcuse.pdf. 

. 

17 
•	 KQ 1: Background (recent trends in the use and quality of CRC screening tests); 

•	 KQ 2: Factors influencing use of CRC screening; 

•	 KQ 3: Effective strategies for increasing appropriate use of CRC screening and followup; 

•	 KQ 4: Current and projected capacities to deliver CRC screening and surveillance at the 

population level; 

•	 KQ 5: Effective approaches for monitoring use and quality of CRC screening; and 

•	 KQ 6: Needed research to make progress and have greatest public health impact in 

promoting the appropriate use of CRC screening. 

Figure 1 depicts how we believe various factors interact to influence the appropriate use of 

CRC screening tests. The boxes are indicative of factors or outcomes of the process of obtaining 

appropriate tests; the circles are meant to depict some interaction or decision point in the process 

(i.e., the interaction between physician and patient and the patient’s decision point). KQs 1-5 are 

called out in the figure (dotted lines); the societal and health system factors are assumed to affect 

all steps in the process. 

Figure 1. Analytic framework for the appropriate use of colorectal cancer screening 

COLO, colonoscopy; CRC, colorectal cancer; CT COLO, computed tomographic colonography; DNA Stool, Deoxyribonucleic acid fecal test; 

FIT, fecal immunochemical test; FS, flexible sigmoidoscopy; gFOBT, guaiac-based fecal occult blood test; KQ, key question; MD, medical 

doctor. 

Specifically, both KQ 1, which pertains to trends in use and quality of colorectal cancer 

screening, and KQ 5, which pertains to monitoring the use and quality, are considered to be 

outcomes of the process depicted in Figure 1. In the remainder of this systematic review, we 

assess the changes in trends over time and how the use and quality of the specific tests (i.e., 

colonoscopy, sigmoidoscopy, computed tomography [CT] colonography, and stool tests) are 

. 

18 
monitored. This includes paying particular attention to issues such as the extent to which 

overutilization and/or underutilization of tests is evident.21-22 

Many factors have been shown in the literature to influence both the use and quality of tests. 

Although the patient is ultimately the one to decide whether to obtain screening,23 a discussion 

with the health care provider about screening needs and options can directly affect the 

decision.24-25 This discussion is depicted in the analytic framework as the point at which an 

interaction between key patient and provider characteristics occurs to guide the discussion. 

As shown in the two boxes on the far left of the analytic framework (Figure 1), both the 

patient and the provider bring characteristics to this interaction that are immutable yet likely to 

influence the provider’s recommendations for CRC screening and the patient’s ultimate decision 

to seek it. Termed “predisposing” by Green and Kreuter, these factors exert their effects before a 

behavior occurs by increasing or decreasing a person’s or a population's motivation to undertake 

that particular behavior.26 Predisposing patient characteristics that may influence the ultimate 

decision related to CRC screening include 

•	 family history of CRC; 

•	 perceived risk or understanding of whether they are likely to be diagnosed with CRC; 

•	 education level, income, and other socioeconomic factors;27 and 

•	 location of residence (i.e., proximity to screening facilities and/or providers).28 

Predisposing physician characteristics that have been shown to influence screening 

recommendations24,29 include 

•	 perceived effectiveness of each type of CRC screening test; 

•	 physician demographic characteristics such as age, whether solo or group practice, 

and location of practice; and 

medical training and awareness of current screening guidelines. 

Literature Search 

To identify articles relevant to each KQ we searched three electronic databases— 

MEDLINE®, the Cochrane Library, and the Cochrane Central Trials Registry—for articles 

published from January 1998 through September 2009. We used either Medical Subject 

Headings (MeSH or MH) as search terms when available or key words when appropriate. MeSH 

terms for our searches included colorectal neoplasms, colonoscopy, sigmoidoscopes; major 

headings included mass screening; and key terms included stool test, FOBT, and DNA stool. The 

full search strategy of exact search strings is presented in Appendix A.†

 Our initial searches of electronic databases produced 3,029 unduplicated records. We 

supplemented our electronic searches by manually searching reference lists of included studies, 

pertinent review articles, and editorials. Additional included studies were identified from 

recommendations of members of the TEP and by peer reviewers. We imported all citations into 

an electronic database (EndNote X.3). 

†

 Appendixes and evidence tables cited in this report are available at 

http://www.ahrq.gov/downloads/pub/evidence/pdf/crcuse/crcuse.pdf. 

. 

19 
Study Selection Process 

Inclusion and Exclusion Criteria 

As noted in Chapter 1, this systematic review focuses on the use and quality of CRC 

screening procedures. We developed detailed eligibility criteria with respect to population, 

interventions, outcomes, time period, and study design (Table 1). We limited eligible studies to 

those conducted in the United States so that the data would reflect domestic health care concerns, 

practices, and guidelines. We also restricted our searches to studies published in 1998 or later to 

ensure that results had relevance to current trends and practice for CRC screening. We excluded 

studies that (1) were published in languages other than English, (2) did not report information 

pertinent to the KQs, (3) had fewer than 30 subjects for randomized or nonrandomized controlled 

trials or fewer than 100 subjects for observational studies, (4) were not original research, or (5) 

evaluated interventions that were conducted in academic settings that would not be applicable to 

most practice settings. 

Table 1. Inclusion/exclusion criteria 

Category Inclusion Criteria Exclusion Criteria 

Study population Humans, all races, ethnicities, cultural 

groups 

Asymptomatic for CRC and not at 

increased risk for CRC OR at 

increased risk for CRC because of a 

family history of CRC or polyps, or 

because of a history of polyps at prior 

colonoscopy 

Studies that exclusively focus on CRC screening for 

patients with a family history 

Patients with diagnosis of any of the following: 

• Genetic diagnosis of FAP or suspected FAP without 

genetic testing evidence 

• Genetic or clinical diagnosis of HNPCC (also known 

as Lynch syndrome) or individuals at increased risk 

of HNPCC 

• Inflammatory bowel disease, chronic ulcerative 

colitis, or Crohn’s disease 

• Colon and/or rectal cancer 

• Other hereditary polyposis syndromes 

Studies that assess whether certain groups are at greater 

risk for CRC than others (e.g., people with comorbidities 

such as diabetes, liver transplant) 

Study outcomes KQ 2: Factors influencing 

testing/screening rates only or CRC 

screening discussions (e.g., 

predisposing patient and provider 

characteristics, health system factors, 

interventions) or quality of CRC 

screening 

KQ 3: Interventions focused on 

changing appropriate CRC screening 

rates among a specified population 

and the rates are presented 

KQ 2: Outcomes of knowledge, risk perception, 

providers’ attitudes toward testing, and/or their referrals 

to testing (which include no screening outcome data) 

KQ 3: Changes in attitudes, beliefs, or intentions to 

obtain screening 

Other criteria specific to outcomes: 

Outcomes not directly addressing at least one KQ 

Cost-effectiveness, cost/benefit, or cost-utility of CRC 

screening for both included or excluded procedures 

CAD, computer-aided detection; CRC, colorectal cancer; CT, computed tomography; CTC, computed tomographic colonography; DNA Stool, 

Deoxyribonucleic acid fecal test; FAP, familial adenomatous polyposis; FIT, fecal immunochemical test; FOBT, fecal occult blood test; FS, 

flexible sigmoidoscopy; gFOBT, guaiac-based fecal occult blood test; GI, gastrointestinal; FS, flexible sigmoidoscopy; HNPCC, hereditary 

nonpolyposis colorectal cancer; KQ, key question; MR, magnetic resonance; MRI, magnetic resonance imaging; N, number; PET, positron 

emission tomography; RCT, randomized controlled trial. 

. 

20 
Table 1. Inclusion/exclusion criteria (continued) 

Category Inclusion Criteria Exclusion Criteria 

Study outcomes KQ 4: Available number of screening Assessment of whether a procedure (usually two 

(continued) providers and related 

equipment/facilities and support 

personnel to conduct the tests (nurses, 

etc.) 

KQ 5: Existence and adequacy of 

systems for monitoring CRC 

screening, CRC screening 

discussions, quality of CRC screening 

procedures compared to each other) is better at 

diagnosing/more effective than other procedures (usually 

retrospective) 

Assessment of different risk factors for CRC (e.g., diet in 

relation to diagnosis of CRC, calcium supplements, 

women taking hormone replacement therapy) and 

relation to incidence and/or mortality 

Treatment of complications (e.g., perforation) 

Treatment of CRC itself 

Study geography United States All other countries 

Time period for 

data collection 

1/1/1998–9/30/2009 Data collection began before 1/1/1998 

Interventions Colonoscopy 

Sigmoidoscopy (or FS) 

CTC (or virtual colonoscopy with only 

CT) 

Double Contrast Barium Enema 

(DCBE) 

Stool tests: 

• DNA stool 

• FIT 

• gFOBT (including Hemoccult® II 

and Hemoccult® SENSA®) 

Office FOBT (unless described/tested along with one of 

the included interventions) 

• MRI colonoscopy (or virtual colonoscopy with MRI) 

• Genetic testing 

• Ultrasound 

Any other tests, including: 

• Any unapproved tests 

• Included procedures combined with others (CTC 

with stool tagging, CTC with CAD technology) 

• Carbon dioxide insufflation during colonoscopy 

• Whole colonic imaging 

• Chromoendoscopy 

• PET and/or PET in combination with CTC, etc. 

• Bidirectional endoscopy 

• Laparoscopy with colonoscopy 

• Molecular screening 

• Submucosal injection polypectomy 

• Upper GI scope/gastroscope 

Studies examining the use of any of the included tests for 

the monitoring or assessment of a condition or disorder 

(e.g., diverticulitis) and therefore not for screening or 

surveillance of abnormal screenings for CRC 

Studies reporting on the use of included procedures in 

the surveillance of CRC 

Use of any included procedures to stage cancer (e.g., 

CTC) 

Studies testing the differences in sedation, dyes, and 

bowel cleansing methods during included procedures 

Publication 

language 

English All other languages 

. 

21 
Table 1. Inclusion/exclusion criteria 

Category Inclusion Criteria Exclusion Criteria 

Admissible 

evidence (study 

Original research that provides 

sufficient detail regarding methods and • Single case reports or small case series 

design and other results to enable use and adjustment • Systematic reviews 

criteria) of the data and results; relevant 

outcomes must be able to be 

abstracted from data presented in the 

papers 

• Ecologic studies 

• Historical comparisons 

KQ 3: Studies without comparison group (e.g., pre/post 

Eligible study designs: 

• RCTs 

• Nonrandomized controlled trials 

• Observation studies—prospective 

and retrospective cohort studies, 

case-control studies, and crosssectional studies 

• Modeling studies 

Eligible sample sizes: 

• RCTs: N ≥30 

• Nonrandomized controlled trials: 

N ≥ 30 

• Observational studies: N ≥ 100 

only were excluded because they are generally unable to 

determine whether any changes in outcomes were due to 

a particular intervention as opposed to secular trends or 

other changes within a practice or setting) 

We examined abstracts of all articles to determine whether studies met our eligibility criteria. 

Two members of our research team reviewed each abstract independently for inclusion or 

exclusion, using an Abstract Review Form (Appendix B).‡

 If one reviewer concluded on the 

basis of the abstract that the article should be considered in the review, we obtained the full text. 

Two members of our research team then independently reviewed each full-text article for 

inclusion or exclusion using a Full Text Review Form (Appendix B). The two relevant reviewers 

discussed disagreements; when they could not reach consensus, the team met and discussed the 

article to determine as a group whether the study met eligibility criteria. Articles that did not 

meet criteria for inclusion are listed in Appendix D along with reasons for exclusion. 

KQs 1 and 6, although part of this report, are not part of the systematic review. Therefore, 

studies described or discussed for those KQs did not have to satisfy final inclusion/exclusion 

criteria; such articles are not included in the overall number of included studies for the 

systematic review. We developed a “Background” category for articles that could provide useful 

information for KQ 1, KQ 6, the introduction, or the discussion. 

Literature Synthesis 

Data Abstraction 

We designed and used a structured data abstraction form. Trained reviewers abstracted data 

from each study and assigned an initial quality rating. A second reviewer read each abstracted 

article, evaluated the accuracy, completeness, and consistency of the data abstraction, and 

‡

 Appendixes and evidence tables cited in this report are available at 

http://www.ahrq.gov/downloads/pub/evidence/pdf/crcuse/crcuse.pdf. 

. 

22 
confirmed the quality rating. If differences in quality ratings could not be resolved by discussion, 

a third senior reviewer was involved. The full research team met regularly during the article 

abstraction period to discuss global issues related to the data abstraction process. 

The final evidence tables are presented in their entirety in Appendix C.§

 Studies are presented 

in the evidence tables alphabetically by the last name of the first author. A list of abbreviations 

and acronyms used in the tables appears at the beginning of Appendix C. 

Rating Quality of Individual Studies 

To assess the quality (internal validity or risk of bias) of studies, we used predefined criteria 

based on those described in the AHRQ Methods Guide for Comparative Effectiveness Reviews 

(ratings: good, fair, poor).30 

Elements of quality assessment for trials included, among others, the methods used for 

randomization, allocation concealment, and blinding; the similarity of compared groups at 

baseline; maintenance of comparable groups; overall and differential loss to followup; and the 

use of intention-to-treat analysis. We assessed observational studies based on the potential for 

selection bias (methods of selection of subjects and loss to followup), potential for measurement 

bias (equality, validity, and reliability of ascertainment of outcomes), adjustment for potential 

confounders, and statistical analysis. 

In general terms, a “good” study has the least bias and results are considered to be valid. A 

“fair” study is susceptible to some bias but probably not sufficient to invalidate its results. The 

fair-quality category is likely to be broad, so studies with this rating will vary in their strengths 

and weaknesses. A “poor” rating indicates significant bias (stemming from, e.g., serious errors in 

design, analysis reporting large amounts of missing information, or discrepancies in reporting) 

that may invalidate the study’s results. 

Studies that met all criteria were rated good quality. The majority of studies received a 

quality rating of fair. This category includes studies that presumably fulfilled all quality criteria 

but did not report their methods to an extent that answered all our questions. Thus, the fairquality category includes studies with quite different strengths and weaknesses. Studies that had 

a fatal flaw (defined as a methodological shortcoming that leads to a very high probability of 

bias) in one or more categories were rated poor quality and excluded from our analyses. Poorquality studies and reasons for that rating are presented in Appendix F. 

Grading Strength of Evidence 

We evaluated the overall strength of evidence for the questions addressing the main 

outcomes of our review (KQs 3, 4, and 5) based on an approach devised for AHRQ’s Method 

Guide.30-31 Developed to grade the overall strength of a body of evidence, this approach 

incorporates four key domains: risk of bias, consistency, directness, and precision. It also 

considers other optional domains that may be relevant for some scenarios, such as a doseresponse association, plausible confounding that would decrease the observed effect, strength of 

association (magnitude of effect), and publication bias. The evaluation of risk of bias includes 

assessment of study design and aggregate quality of studies.31 

§ Appendixes and evidence tables cited in this report are available at 

http://www.ahrq.gov/downloads/pub/evidence/pdf/crcuse/crcuse.pdf. 

. 

23 
We graded evidence as consistent when effect sizes across studies were in the same direction 

and had a narrow range. When the evidence linked the interventions directly to our outcomes of 

interest, we graded the evidence as being direct. We graded evidence as being precise when 

results had a low degree of uncertainty. At least two members of our research team evaluated the 

overall strength of evidence for each outcome based on a qualitative assessment of strength of 

evidence for each domain and reconciled all disagreements. 

The levels of strength of evidence are shown in Table 2. As mentioned, we present the 

strength of evidence assessments only for KQs 3, 4, and 5. These are the three KQs that are 

analytic and required an assessment of the body of literature available for this review. KQ 2 is 

descriptive and did not lend itself to an assessment of the strength of evidence. The strength of 

evidence tables appear in Chapter 4 as part of the presentation of results for KQs 3, 4, and 5. 

Table 2. Strength of evidence grades and definitions 

Grade Definition 

High High confidence that the evidence reflects the true effect. Further research is very 

unlikely to change our confidence in the estimate of effect. 

Moderate Moderate confidence that the evidence reflects the true effect. Further research 

may change our confidence in the estimate of effect and may change the estimate. 

Low Low confidence that the evidence reflects the true effect. Further research is likely 

to change our confidence in the estimate of effect and is likely to change the estimate. 

Insufficient Evidence either is unavailable or does not permit estimation of an effect. 

Source: Owens et al., 200931 

Applicability 

We evaluated the applicability of the evidence based on a qualitative assessment of the 

population, intensity or quality of treatment, choice of the comparator, outcomes, and timing of 

followup. We based our parameters for evaluation on guidance provided by AHRQ’s Methods 

Guide.30 Specifically, we considered whether enrolled populations differ from target populations, 

whether studied interventions are comparable with those in routine use, whether comparators 

reflect best alternatives, whether measured outcomes are known to reflect the most important 

clinical outcomes, and whether followup was sufficient. 

Peer Review 

This draft report was subjected to external peer review by eight individuals who were experts 

in fields relevant to CRC screening or from various stakeholder and user communities (listed in 

Appendix E).** We provided the draft report to them on September 14, 2009. All eight provided 

thoughtful feedback on the report, including providing us with additional references that we 

should consider for inclusion in the final report. We reviewed all additional references and 

included those that were appropriate and within the scope of this report. We also addressed all 

comments and revised the report accordingly. 

** Appendixes and evidence tables cited in this report are available at 

http://www.ahrq.gov/downloads/pub/evidence/pdf/crcuse/crcuse.pdf. 

. 

24 
Chapter 3. Overview of Trends in Use and Quality of 

CRC Screening 

We present here the results of our summary of information specific to trends in the use and 

quality of colorectal cancer (CRC) screening. Based on instructions from the Office of Medical 

Applications of Research (OMAR) at the National Institutes of Health (NIH) and from the 

Agency for Healthcare Research and Quality (AHRQ), we treated this question as a background 

question rather than a question for systematic review. For that reason, we present our findings 

here, separate from the four key questions (KQs) for which we present our analysis and synthesis 

of literature (Chapter 4). The articles that inform this section came from the general search that 

we conducted for all KQs, from multiple hand-searches of reference lists in those articles, and 

from suggestions of our expert Technical Expert Panel (TEP) and Peer Reviewers. 

KQ 1: What are the Recent Trends in the Use and Quality of 

CRC Screening? 

Trends in Incidence and Mortality from Colorectal Cancer 

Colorectal cancer is the third most common nonskin cancer among men and among women; 

an estimated 146,970 people in the United States were newly diagnosed with this disease in 

2009.32 The overall age-adjusted incidence rate for CRC has decreased in both men and women 

and in all ethnic groups since the mid-1980s, with an overall 3 percent annual decline between 

1998 and 2005.33 CRC incidence is higher among non-Hispanic blacks than among non-Hispanic 

whites; it is lower among Asian-Pacific Islanders and Hispanics than among non-Hispanic 

whites. 

Colorectal cancer is the also the third-highest cause of cancer death among men and women; 

an estimated 49,920 deaths were attributed to this disease in 2009 in the United States.32 The 

overall age-adjusted mortality rate from CRC has decreased in both men and women since the 

mid-1980s; the annual percent decline between 2002 and 2005 was 4.3 percent.33 CRC mortality 

rates declined for non-Hispanic black, non-Hispanic white, and Asian-Pacific Islander men and 

women. The rates dropped for Hispanic men but not for Hispanic women.33 CRC mortality is 

higher in non-Hispanic blacks than non-Hispanic whites; it is lower in Asian-Pacific Islanders 

and Hispanics than in non-Hispanic whites. The gap in CRC mortality between non-Hispanic 

blacks and non-Hispanic whites did not change between 1997 and 2005.34 

Measures of CRC Screening 

Several approaches have been used for measuring the percentage of a population that is up to 

date on CRC screening according to the national guidelines. Research studies of this question 

have most often used patient self-reports, but administrative databases, medical record reviews, 

and physician reports have also been used. A field study for the National Committee on Quality 

Assurance (NCQA) compared three different measurement approaches for assessing rates of 

CRC screening: patient surveys, administrative datasets, and a hybrid approach that performed 

medical record review for patients who did not have evidence of screening by administrative 

data.35 Among the five health plans examined in the NCQA study, two did not show much 

25 
difference between administrative and hybrid approaches, but the other three plans had 5 percent 

to 15 percent higher rates by the hybrid approach than by administrative data alone.35 

In all five plans, patient surveys (surveys patterned on the standard questions used by the 

Behavioral Risk Factor Surveillance System [BRFSS] from the Centers for Disease Control and 

Prevention [CDC]) gave screening rates higher than the hybrid and administrative approaches; 

the differences ranged from 2.4 percent to 23.3 percent for the hybrid approach and from 7.9 

percent to 34.8 percent for the administrative approach. The differences between the survey and 

administrative approaches were lower for fecal occult blood test (FOBT) screening (difference 

ranged from 0.4 percent to 11.3 percent) than for flexible sigmoidoscopy (FS) and colonoscopy 

(difference for colonoscopy ranged from 7.1 percent to 26.9 percent). 

One major reason for higher estimates from surveys is that nonrespondents are likely to have 

had less screening over time than respondents. Thus, one would expect that surveys would 

overestimate screening when response rates are low. When response rates are high, other studies 

have found a smaller degree of overestimation of screening rates, although some overestimation 

is still present.36-38 Other studies have found that self-report overestimates screening rates more 

with FOBT than with colonoscopy.39-40 Ultimately, because of changes in guidelines, as well as 

how questions are asked and current use is operationalized, measures of CRC screening have 

been challenging to standardize. For this reason, drawing valid conclusions on use is 

problematic. 

Changes in Medicare Coverage of CRC Screening 

In January 1998, the Centers for Medicare and Medicaid Services started covering CRC 

screening for Medicare beneficiaries; the tests included FOBT and FS as recommended by the 

American Cancer Society (ACS). On July 1, 2001, Medicare extended coverage for screening to 

colonoscopy every 10 years. 

Changes Over Time in National Surveys of Screening 

We found reports of screening rates from large, national surveys in two major sources: the 

National Health Interview Survey (NHIS), administered by the National Center for Health 

Statistics (NCHS), and BRFSS. NHIS is a personal household interview that contains a core set 

of questions plus additional supplements on specific topics. The CRC screening questions were 

revised in the late 1990s. 41 Before 2000, the NHIS did not distinguish between home and office 

FOBT and did not distinguish among endoscopic tests (e.g., proctoscopy, FS, colonoscopy). In 

addition, the 2000 NHIS asked about screening longer than 3 years before the survey. 42 Thus, 

screening rates before 2000 included some number of office FOBTs within the previous 1 or 2 

years and proctoscopy (as well as FS and colonoscopy) within the previous 3 years. Starting in 

2000, up-to-date screening is defined as home FOBT within the previous year, FS within the 

previous 5 years, or colonoscopy within the previous 10 years. The earlier rates from NHIS are 

thus likely an overestimate of the actual screening rates at the time (because of including inoffice FOBT and proctoscopy, and how questions were asked) compared with rates starting in 

2000. Also, since respondents had been asked about endoscopy use in the past 3 years only, this 

rate could be an underestimate of screening for these tests. NHIS interviewers read test 

descriptions to all eligible respondents for the first time in 2003. 43 

BRFSS is a national, random-digit-dial telephone survey administered in the United States to 

respondents 18 and older. BRFSS asked about FS and proctoscopy (not distinguishing between 

26 
them) until 1999, when the question was changed to ask about FS or colonoscopy (again, not 

distinguishing between them). Before 2001, BRFSS did not allow for screening intervals longer 

than 5 years. Thus, BRFSS estimates before 2001 are for FOBT within the past year or lower 

endsocopy within the past 5 years. Starting in 2001, most estimates are for FOBT in the past year 

or lower endoscopy within the previous 10 years. 

BRFSS response rates vary by state. For 1997, the overall median response rate by state was 

62.1 percent, in 1999 it was 55.2 percent, and in 2001 it was 51.1 percent (range 33.3 percent to 

81.5 percent). In 2002, the median response rate was 58.3 percent; in 2004 it was 52.7 percent, 

and in 2006 it was 51.4 percent. Thus, not all state estimates have the same validity.44 About 

3 percent of respondents were eliminated from the 2002 and 2004 analyses because they refused 

to answer or did not know the answer; in 2006, 4.5 percent were eliminated.45 

Table 3. Trends in screening according to Estimates from NHIS and BRFSS the National Health Interview Survey 

Year Men Women Combined In 1987 by NHIS data (Table 3), 22 percent of men 1987a

 22% 24.2% NR

and 24.2 percent of women had had an FOBT within the 1992a

 29.4% 28.2% NR 

previous 2 years or FS, proctoscopy, or colonoscopy 1998a

 37.1% 30.2% NR 

within 3 years.41 For women, these screening rates 2000b

 NR NR 37.1% 

2003b

 46.5% 43.1% NR increased to 28.2 percent in 1992 and 30.2 percent in 2005b

 NR NR 50.0% 1998. For men, rates increased to 29.4 percent in 1992 

NR, not reported. and 37.1 percent in 1998.41 In 2000 (using the more a

 Any fecal occult blood test (FOBT) within past 2 years 

restrictive definition of screening), 37.1 percent of both or flexible sigmoidoscopy (FS), proctoscopy, or 

men and women had had at least one of these tests.42 colonoscopy within past 3 years. In b

 Home FOBT within the past year, FS within the past 5 

2003, NHIS found that 46.5 percent of men and 43.1 years, or colonoscopy within the past 10 years. 

percent of women had been screened43 and in 2005, 50.0 

percent of both men and women had been screened.46 

The 1997 BRFSS (Table 4) found that 41 percent of respondents ages 50 years and older had 

had either an FOBT in the previous year or lower endoscopy (either FS or proctoscopy) in the 

previous 5 years. In 1999, this percentage had increased 

Table 4. Trends in CRC screening to 44 percent.47 The 2001 BRFSS found that 53.1 according to the Behavioral Risk Factor percent of people in this age group reported having Surveillance Survey 

either an FOBT within the previous year or lower Year Men Women Combined endoscopy (either FS or colonoscopy) within the 1997a NR NR 41%

previous 10 years.44 In 2002, this percentage was 53.9 1999b NR NR 44% 

percent; in 2004, it was 56.8 percent and in 2006, it was 2001c NR NR 53.1% 

2002c 60.8 percent.45 55.3% 53.1% 53.9%

2004c 58.0% 55.9% 56.8% 

2006c 61.5% 60.4% 60.8% Population Subgroups 

NR, not reported. 

a

 Any fecal occult blood test (FOBT) within the past year The changes in definitions of tests and testing or lower endoscopy (proctoscopy or flexible 

sigmoidoscopy [FS]) within the past 5 years. intervals noted above cloud the data concerning CRC b

 Any FOBT within the past year or lower endoscopy (FS screening rates among population subgroups, including or colonoscopy) within the past 5 years. 

c

 Home FOBT within the past year or lower endoscopy racial, ethnic, age, sex or gender, income, and (FS or colonoscopy) within the past 10 years. educational groups. One BRFSS study used common 

coding and standard definitions over the years 2002 to 2006 for the data in Table 5.45 Although 

the absolute percentages here are slightly higher than those from the NHIS (partly because of 

higher response rates in NHIS and the use of telephone rather than in-person interviews), the 

27 
trends are the same in both surveys. Higher overall absolute screening rates are seen in older 

versus younger people, in white versus black populations, and in non-Hispanic versus Hispanic 

people. Higher education, higher income, and health insurance coverage are also associated with 

higher screening rates. 

Table 5. Percentage of respondents 50 years of age or order who reported receiving a fecal occult blood test 

within 1 year and/or a lower endoscopy* within 10 years, by selected characteristics—BRFSS, United States, 

2002, 2004, and 2006† 

2002 2004 2006‡ 

Characteristic % (95% CI) % (95% CI) % (95% CI) 

Total 

Age Group (years) 

50−64 

53.9 

47.9 

(53.4 – 54.5) 

(47.1 − 48.6) 

56.8 

50.2 

(56.3 – 57.3) 

(49.6 – 50.9) 

60.8§

 54.7 

(60.4 − 61.3) 

(54.1 − 55.4) 

≥65 62.3 (61.5 − 63.1) 65.9 (65.2 − 66.6) 69.3 (68.6 − 69.9) 

Sex 

Male 55.3 (54.4 – 56.1) 58.0 (57.2 – 58.8) 61.5 (60.8 – 62.3) 

Female 53.1 (52.4 – 53.8) 55.9 (55.3 – 56.5) 60.4 (59.8 – 61.0) 

Race 

White, non-Hispanic 55.4 (54.9 – 55.9) 58.4 (57.9 – 58.8) 62.6 (62.1 – 63.0) 

Black, non-Hispanic 52.0 (49.8 – 54.2) 55.2 (53.3 – 57.1) 59.0 (57.3 – 60.6) 

Asian/Pacific Islander 42.7 (36.4 – 49.1) 47.6 (41.0 – 54.4) 55.9 (51.0 – 60.7) 

American Indian/Alaska Native 51.2 (45.6 – 56.8) 47.0 (41.7 – 52.4) 48.4 (43.5 – 53.2) 

Other 

Ethnicity║

Non-Hispanic 

43.3 

54.8 

(39.4 – 47.2) 

(54.3 – 55.4) 

46.2 

57.8 

(42.1 – 50.3) 

(57.3 – 58.2) 

46.2 

62.0 

(42.7 – 49.8) 

(61.5 – 62.4) 

Hispanic 43.9 (40.6 – 47.3) 46.2 (43.2 – 49.2) 47.2 (44.5 – 49.9) 

Education level 

Less than high school diploma 41.0 (39.3 – 42.7) 43.9 (42.1 – 45.6) 45.5 (43.8 – 47.2) 

High school diploma or equivalent 50.7 (49.7 – 51.6) 52.9 (52.1 – 53.8) 56.7 (55.9 – 57.4) 

Some college/technical school 56.5 (55.5 – 57.5) 58.5 (57.5 – 59.4) 62.6 (61.8 – 63.5) 

College degree 

Annual household income 

62.0 (61.0 – 63.0) 64.8 (63.9 – 65.6) 68.7 (67.9 – 69.5) 

<$15,000 43.4 (41.5 – 45.2) 45.0 (43.3 – 46.7) 48.4 (46.8 – 50.1) 

$15,000−$34,999 49.1 (48.1 – 50.1) 51.2 (50.2 – 52.2) 53.9 (53.0 − 54.9) 

$35,000−$49,999 56.0 (54.7 – 57.4) 58.6 (57.4 – 59.8) 62.0 (60.8 – 63.1) 

$50,000−$74,999 59.4 (57.5 – 61.3) 62.1 (60.7 – 63.5) 67.2 (66.1 – 68.3) 

≥$75,000 64.8 (63.2 – 66.4) 68.1 (66.8 – 69.3) 70.4 (69.3 – 71.4) 

Health insurance coverage 

Yes 55.9 (55.3 – 56.5) 58.9 (58.3 – 59.4) 63.0 (62.5 – 63.5) 

No 33.1 (30.8 – 35.5) 34.7 (32.2 – 37.3) 36.7 (34.3 – 39.1) 

BRFSS, Behavioral Risk Factor Surveillance System; CI, confidence interval. 

* Sigmoidoscopy or colonoscopy.

†

 Adapted from Use of colorectal cancer tests—United States, 2002, 2004, and 2006”; Morbidity and Mortality Weekly Report; 2008 March 14; 

57(10);253-258.

‡

 Age standardized to the 2006 BRFSS population ages 50 years or older. §

 Wald F-test of significance for differences across the three survey years, P < 0.001. 

║ Race and ethnicity are not mutually exclusive. 

Medical Practice Rates 

Several studies provided information about CRC screening rates in medical practices, 

although we found no practice with uniform methods that could provide trend data over time. 

One chart review study of a sample of 12 diverse primary care practices in Michigan in 2003 

found that CRC screening rates varied from 24 percent to 60 percent of eligible patients being up 

to date (FOBT in the past year, FS in the previous 5 years, or colonoscopy in the previous 10 

years).48 Another study examined CRC screening for 21,833 patients who were continuous 

members of an integrated health plan in the Midwest for the 5-year period ending December 31, 

28 
2003. Using automated records, the authors classified 54 percent of patients as being up to date 

for CRC screening (having received at least three FOBT kits, one FS, one colonoscopy, or one 

barium enema over that period).49 

Frequency of Discussions about CRC Screening 

We found no trend data about this topic, but we did find several relevant articles. One study 

from 1998 to 2006 in southern California collected data from surveys with 191 physicians and 

5,978 patients, asking about previous screening and discussions about several conditions, 

including FOBT and FS.50 In this study, 37 percent of patients had discussed FOBT with their 

physician and 31 percent had discussed FS. 

A second study audiotaped interactions between patients of the Veterans Health 

Administration (VA) eligible for CRC screening and their physicians.51 The study defined nine 

elements of informed decisionmaking and scored the occurrence of each element in 91 

audiotapes of patients who had a CRC screening test ordered during that visit. Informed 

decisionmaking elements included such issues as discussion of the patient’s role in 

decisionmaking, discussion of alternatives, discussion of uncertainties, assessment of patient 

understanding, and asking for patient preferences. The median number of elements addressed 

was 1. No single element was addressed in more than 50 percent of interactions. Only 6 percent 

of interactions discussed uncertainties or patient understanding. A telephone and in-person 

survey asked 65 academic and community primary care physicians to present CRC screening to 

the investigator as if the investigator were a patient.52 Only 33.8 percent of respondents discussed 

the patient’s role in the decision, 16.9 percent discussed benefits and risks of screening 

strategies, and 10.8 percent provided alternative screening strategies. 

A 2005 survey asked 270 primary care physicians connected with Northwestern University 

Feinberg School of Medicine to rate the importance of various general communication tasks 

relevant to CRC screening and to report how often they accomplish those tasks with screeningeligible patients.53 Talking with patients was rated 9.5 out of 10 in importance; physicians 

reported that they accomplished this with 84.4 percent of patients. Discussing colonoscopy was 

rated 9.2; physicians reported accomplishing this with 84.8 percent of patients. Explaining test 

benefits was rated 9.0; physicians reported that they accomplished this for 79.3 percent of 

patients. Explaining test risks was rated 8.1; physicians reported this behavior for 63 percent of 

eligible patients. Eliciting patient views or preferences was rated 8.0; physicians reported 

accomplishing this for 65.7 percent of patients. Presenting more than one option was rated only 

6.4 on the same scale and discussing FOBT was rated as 5.0; physicians reported accomplishing 

an FOBT discussion with 54 percent of eligible patients. 

This same study also examined videotapes from an existing dataset of primary care 

encounters.53 The authors found 18 videotaped encounters from a database of 271 interactions 

with patients’ ages 49 to 80 years in which the physician discussed CRC screening for the first 

time. Two authors viewed each videotape to determine to what extent physicians achieved the 

tasks they rated in the survey above. The benefits of the screening test were described in 28 

percent of encounters; the risks were described in 0 percent of the encounters. In 28 percent of 

videotaped encounters in which CRC screening was discussed, physicians elicited patient views 

or preferences for CRC screening. 

A survey of 2,501 patients of an integrated health care delivery system in southeastern 

Michigan who were continuously enrolled from 1999 to 2003 was able to link patients’ 

responses to an automated health record system to determine CRC screening over the 5-year 

29 
study period.54 Only 54 percent of this cohort was screened during the 5 years. About 80 percent 

of respondents (50.4 percent response rate) reported having a discussion with their physician 

about CRC screening. Of those having a discussion, 71 percent reported discussing colonoscopy 

and 41 percent FOBT. About 66 percent of patients reported that their physician discussed the 

pros and cons of different tests; 33 percent said that they had been asked about their preference 

for different types of tests and 39 percent were offered a choice among available tests. The 

association between those who had been offered a choice and receipt of a CRC screening test 

was negative; in this case, being offered a choice was associated with a lower screening rate. The 

usual length of these discussions and the relationship between patient report and actual 

discussion was not reported. 

In this report, we distinguish between discussions of CRC screening between physicians and 

patients (covering such areas as pros and cons of screening options and eliciting patient 

preferences) as opposed to a simple physician recommendation of CRC screening (which is 

discussed in KQ 2). Although discussion and recommendation are not the same, recommendation 

would likely be a part of most discussions of CRC screening between physician and patient. 

Patient awareness of CRC screening is another likely result of CRC discussions. When there has 

been no physician recommendation and when patients are unaware of CRC screening, it is likely 

that there have been no discussions. Thus, lack of awareness and lack of a physician 

recommendation are two of the more frequent reasons that people who have not been screened 

give for not having obtained such tests.21,55-57 

Test-Specific Trends 

Over time, the percentage of eligible people screened with FOBT and FS has declined while 

the percentage screened with colonoscopy has increased. For example, the proportion of BRFSS 

respondents who had had an FOBT within 1 year declined from 2002 to 2006: 21.6 percent in 

2002, 18.5 percent in 2004, 16.2 percent in 2006. The percentage who had had a lower 

endoscopy (either FS or colonoscopy) in the previous 10 years increased over the same period: 

44.8 percent in 2002, 50.1 percent in 2004, and 55.7 percent in 2006.45 

One national study examined the Medicare administrative database to determine trends in the 

use of various CRC screening tests between 1995 and 2003. Medicare started reimbursing for 

screening colonoscopy on July 1, 2001.58 In 1995, 18.0 percent of Medicare beneficiaries 

received FOBT; in 2003, the figure was 14.3 percent. The percentage of people who received FS 

in 1995 was 3.9 percent, decreasing to 1.2 percent in 2003. The rate for colonoscopy, by contrast, 

rose: in 1995, 3.9 percent of Medicare beneficiaries received colonoscopy; in 2003, the figure 

was 9.4 percent. The relative decline in FS and the relative increase in colonoscopy was greater 

in white patients than in nonwhite patients. These changes were most pronounced after July 

2001. These percentages are for screening received within a 1-year period, rather than the 

percentage of people who are up to date. A second analysis examined the test-specific trends 

within the Medicare population from 1998 to 2005, with similar findings.59 

Other studies using information from the administrative databases of health plans or large 

gastroenterology practices have also found increased use of screening colonoscopy after July 

2001.49,60-62 

In an important study of trends in specific CRC screening test use between 1992 and 2002 in 

the Medicare population, use of FS increased from a mean rate per calendar-year quarter per 

100,000 beneficiaries of 570.6 in 1996-1997 to 691.9 in 1999-2000 (after it was covered by 

Medicare in 1998) and then decreased to 267.5 in 2002-2003, after colonoscopy coverage started 

30 
in 2001.63 Colonoscopy use, by contrast, increased from a mean rate per quarter per 100,000 

beneficiaries of 284.6 in 1996-1997 to 1,918.9 in 2002-2003. This study also found that the 

percentage of CRCs diagnosed at an early stage rose for proximal but not distal cancers after 

2001, indicating the effect of colonoscopy in detecting proximal cancers. Even with this increase 

in screening associated with Medicare reimbursement, many Medicare beneficiaries remained 

unscreened. 

A study of CRC screening test use from 1998 to 2003 in the VA system, in which physicians 

have no financial incentives to perform colonoscopy, found an increase in overall screening, 

driven primarily by an increased number of FOBTs.64 FOBT as a proportion of all screening tests 

increased from 81.7 percent to 90.4 percent over the study period while screening colonoscopy 

declined from 5.7 percent to 4.7 percent and FS declined from 8.3 percent to 3.6 percent. A 2007 

study of 17,252 patients in the Western Region Tricare Insurance system of the Department of 

Defense found that 71 percent of these beneficiaries were up to date with standard CRC 

screening guidelines, and 83 percent of those who were up to date had had a colonoscopy within 

the previous 10 years.65 

Trends toward screening colonoscopy may be less pronounced among disadvantaged groups 

than among the more advantaged. Although disadvantaged people (e.g., those without health 

insurance) are less up to date with screening, those who are screened may be more likely to be 

screened with FOBT than colonoscopy. One study conducted telephone interviews with 570 

users of private physician offices (3 percent without insurance) and 500 registrants of county 

health centers (44 percent without insurance) in a single geographic area of New York State. 

Fifty-four percent of users of private physician offices and 28 percent of county health center 

registrants had had colonoscopy within the previous 10 years, while more county health center 

registrants had had an FOBT in the past year (31 percent private physician users versus 37 

percent county health center registrants). Seventy percent of the private physician users and 55 

percent of county health center registrants were up to date with national guidelines for CRC 

screening.66 

Beyond the United States, the International Colorectal Cancer Screening Network surveyed 

CRC screening programs that started before May 2004.67 They found 10 organized CRC 

screening programs in seven countries. Of these, five used FOBT only, three used FS only, one 

used FOBT and FS, and one offered colonoscopy only. The program offering only colonoscopy 

was in Poland; the United States was not listed as having an organized program. The FOBT 

programs were split between gFOBT and iFOBT. A variety of pilot programs and research 

initiatives were also listed. 

Patient Preferences for CRC Screening Tests 

We found several studies that asked people about their preferences for CRC screening tests. 

In general, the studies found diversity of opinion, with some people preferring colonoscopy 

(often because of its accuracy) and others favoring FOBT (often to avoid the discomfort and 

inconvenience of colonoscopy). 

One study recruited 323 colonoscopy-naïve supermarket shoppers from a low-to-middleclass neighborhood in Denver, Colorado.68 About half of respondents were non-Hispanic white 

with most of the rest evenly split between African-Americans and Latinos. After a description of 

the tests, 53 percent preferred FOBT and 47 percent preferred colonoscopy. Another study 

recruited 212 primary care patients from the waiting rooms of 3 community health centers and 

one academic medical center.69 Patients were divided nearly equally among white, African31 
American, and Hispanic people. Of the guideline-recommended tests, 37 percent preferred 

colonoscopy, 31 percent FOBT, 15 percent barium enema, and 9 percent sigmoidoscopy. One 

further study recruited 4,042 people who were participating in a multi-center study (84 sites) 

comparing fecal DNA testing with FOBT and colonoscopy.70 Eighty-nine percent of participants 

were white. The participants were asked to complete a questionnaire after completing all three 

study tests. When asked which test they preferred for routine testing, 45 percent selected the 

fecal DNA test, 32 percent FOBT, and 15 percent colonoscopy. 

Geographic Differences 

We found no data on trends about differences in CRC screening rates by geographic factors; 

we did find several relevant reports. Using 2001 BRFSS estimates, states varied dramatically in 

the percentage of people having had an FOBT within the previous 2 years and in the percentage 

of people ever having had FS or colonoscopy.71 For FOBT for white men, the rates ranged from 

14.3 percent in Alabama to 43.7 percent in Vermont. For FS/colonoscopy for white men, the 

rates ranged from 33.5 percent in Oklahoma to 63.5 percent in Delaware. For FOBT for white 

women, the rates ranged from 11.6 percent in Alabama to 46.7 percent in North Carolina. For 

FS/colonoscopy for white women, the rates ranged from 38.3 percent in Kentucky to 62.1 

percent in North Dakota. 

For FOBT for black men, the rates ranged from 4.7 percent in Alabama to 48.6 percent in 

North Carolina. For FS/colonoscopy for black men, the rates ranged from 13.7 percent in 

Tennessee to 56.4 percent in California. For FOBT in black women, the rates ranged from 10.5 

percent in Alabama to 43.3 percent in Massachusetts. For FS/colonoscopy in black women, the 

rates ranged from 35.6 percent in New York to 59.2 percent in Virginia. 

The 2004 BRFSS found variation among the states in the percentage of respondents ages 50 

years and older reporting having had either an FOBT within the previous year or lower 

endoscopy within the previous 10 years.72 Rates ranged from 47.9 percent in Mississippi to 68.2 

percent in Minnesota. 

Health System Rates 

The VA has a performance measure from medical record review for screening for people 

ages 50 to 80 years (FOBT within the past year, FS within the past 5 years, or colonoscopy 

within the past 10 years). With respect to being up to date on CRC screening, 78 percent of 

patients were up to date in 2007 and 79 percent in 2008.73 The VA system has annual CRC 

screening rates from 1996 to the present. A few representative years are the following: 1996: 34 

percent; 2000: 68 percent; 2004: 72 percent; and 2006: 76 percent. 

NCQA, for its Healthcare Effectiveness Data and Information Set (HEDIS) commercial plans 

and using the same definition for being up to date as the VA, reported for 2007 that 55.6 percent 

of patients were up to date. The HEDIS measure is calculated from administrative data followed 

by a chart review for patients with no evidence of screening. No HEDIS trend data were 

available to us. 

Overuse of CRC Screening 

Although most of the previous discussion concerns underuse of CRC screening, overuse is 

also a concern. The two aspects of overuse for which we found evidence in the literature are 

32 
overuse in people who, because of severe comorbidity or advanced age, have little potential to 

benefit and overuse of surveillance colonoscopy. By surveillance colonoscopy, we are referring 

to colonoscopy for patients who have had a previous colonic polyp (and, usually, polypectomy). 

Overuse among persons unlikely to benefit. We found no data concerning trends for 

overuse but did find several relevant reports. Overuse of CRC screening has been documented in 

three studies in the VA system, questioning whether some patients are being screened 

inappropriately.74-76 Some patients are less likely than others to survive for the 5 to 10 years 

necessary to have a chance of benefit from screening. In one study, 18 percent of patients given 

an FOBT kit at a single VA facility had severe comorbidities.76 In the other two studies, of 

multiple VA system sites, people with severe comorbidities were screened as often as people 

with no co-existing illnesses.74-75 

Recently, the US Preventive Services Task Force (USPSTF) recommended that people over 

age 75 not be screened routinely and that people over age 85 not be screened at all.3 Thus, 

screening people over age 85 may also be considered overuse of screening. 

Overuse of surveillance colonoscopy. Another potential for overuse is the frequency of 

surveillance colonoscopy after polypectomy. A 1999-2000 survey of a nationally representative 

sample of 317 gastroenterologists and 125 general surgeons active in colonoscopy surveillance 

(response rate 83 percent) asked for their suggestions for surveillance colonoscopy for four 

clinical scenarios.77 One scenario, the finding of a hyperplastic polyp, confers no additional CRC 

risk and requires no surveillance over routine screening. Yet 24 percent of gastroenterologists 

and 54 percent of general surgeons recommended surveillance colonoscopy, most of them at a 

frequency of 5 years or less. A second scenario, finding a single small adenoma less than 1.0 cm 

in size, is generally classified as a “low risk” situation, and the MSTF guideline is surveillance 

colonoscopy at 5 to 10 years.78 Yet 52 percent of gastroenterologists and 77 percent of general 

surgeons recommended surveillance colonoscopy every 3 years or more often. The authors 

concluded that “these findings suggest considerable over-performance of surveillance 

colonoscopy.”77 A similar study of primary care physicians found even more frequent 

recommendations for surveillance of low-risk patients.79 A study of endoscopists’ 

recommendations for repeat colonoscopy in 10 primary care practices in Virginia and Maryland 

found that endoscopists often recommend colonoscopy more frequently than guidelines 

recommend.80 The mean number of years in which repeat colonoscopy was recommended by 

endoscopists was 7.8 years following normal colonoscopy, 5.8 years following the finding of a 

hyperplastic polyp, and 4.4 years following the finding of 1 or 2 small adenomas. 

An innovative followup study of 1,297 participants in the Polyp Prevention Trial (an RCT of 

a dietary intervention to prevent colorectal adenomas) found evidence of both underuse and 

overuse of surveillance colonoscopy. Among patients with high-risk adenomas (who, according 

to national guidelines, should receive surveillance in 3 years81), only 36 percent had received 

surveillance within 3 years, and only 65.2 percent had had a surveillance examination within 5 

years. Among patients with low-risk adenomas (who should receive surveillance only between 5 

and 10 years of initial screening), however, 39.7 percent had had a surveillance examination 

within 4 years.82 

Misuse Rates 

We define misuse as performance of screening tests in such a way that benefits are reduced 

or harms are increased compared with optimal performance. “Optimal” performance is 

33 
sometimes difficult to define. Thus, we provide frequencies for clearly suboptimal performance 

and harms that could be potentially reduced by improved procedures. 

We found literature on three types of misuse regarding FOBT: use of in-office FOBT when 

the literature is clear that home FOBT is preferable, nonreturn of FOBT cards given to patients, 

and nonfollowup of positive FOBT results with a full colon examination. We also found 

literature on two types of misuse of colonoscopy: high rates of adverse events such as colonic 

perforation and bleeding and nondetection of important colonic lesions. We found little data 

concerning trends for these problems and thus present the current situation as documented in the 

literature. 

Reliance on in-office FOBT is clearly a problem of misuse, substituting a less effective test 

for a more effective one.83 A 1999-2000 national survey of primary care physicians found that 

32.5 percent of physicians used in-office FOBT exclusively; another 41.2 percent used a 

combination of in-office and home-based FOBT.84 Nearly one-third of patients in the 2000 NHIS 

who reported having an FOBT said that the only test they had had was an in-office FOBT.84 

Whether these percentages have changed after this study was done remains unclear. 

Another type of misuse of CRC screening tests is nonreturn of FOBT cards given to patients. 

We found only one study concerning this issue, an RCT of an intervention to improve return of 

FOBT cards in a VA primary care clinic.85 In the control (usual care) arm of this study, 51.3 

percent of patients returned the FOBT cards they were given (mean time to return cards in this 

group was 143 days). 

Still another type of misuse is nonfollowup of positive FOBT screening results. We found 

one study in an integrated health care system that examined trends between 1993 and 2005 in the 

percentage of positive FOBTs that were followed by a complete diagnostic examination within 

1 year.86 This percentage increased from between 57 percent and 64 percent in 1993-1996 to 

between 82 percent and 86 percent in 2000-2005. The authors noted the introduction during 

those periods of tracking systems and screening guidelines. 

Other studies provided information about follow-up rates for positive FOBTs but not trends 

over time. Two studies from the VA (data from 2000-2002) have documented lack of followup 

of positive FOBTs. One study of national VA data found that 41 percent of patients with a 

positive FOBT had not received or been referred for a follow-up test (either colonoscopy or 

barium enema) within 6 months.87 A second study at a single VA center examined chart reviews 

on 538 men who had had a positive FOBT. About 77 percent were referred to gastroenterology; 

only 44 percent underwent full colon examination within 12 months.88 In a study of positive 

FOBTs (76 percent from a screening FOBT) in a large integrated health care system (data from 

2004-2006), fewer than 10 percent of patients had no action taken; colonoscopy was completed 

in 62 percent within a year.89 Three older single-institution studies90-92 (one using 1986 data, one 

using 1998 data, and one using 1993 data) and one study of community medical practices (using 

1994-1996 data)93 examining positive FOBTs from screening programs found from 23 percent to 

46 percent of patients had no follow-up colon evaluation. 

A 1999-2000 survey of 182 health plans (52 percent response rate) by the National Cancer 

Institute found that only 41 percent of plans had any system for delivering and/or monitoring 

CRC screening use; 25 percent had a mechanism for reminding patients when they are due for 

screening; 16 percent had a system for reminding physicians when a patient is due. Fewer than 

15 percent of plans monitored receipt of follow-up care after a positive FOBT.94 

Another form of misuse is a high rate of adverse events during or after colonoscopy. We 

found no data on trends for this topic, but we did find two important reports to highlight. One 

34 
study examined the Medicare database to count adverse events requiring an emergency 

department visit or hospitalization within 30 days of a colonoscopy.20 The risk of colonic 

perforation was about 0.6 per 1,000 colonoscopies. The risk of gastrointestinal bleeding or 

transfusions was 2.1 per 1,000 in a group that was screened and did not have a polypectomy and 

8.7 per 1,000 in a group that had a polypectomy. Some patients also suffered a cardiovascular 

event within 30 days: 9.9 per 1,000 procedures in the screening but no polypectomy group and 

23.4 per 1,000 in the polypectomy group. Adverse events increased with age; people over age 85 

suffered more than twice as many adverse events as people ages 66 to 69. A systematic review 

that pooled US studies before January 2008 found a combined rate of serious complications of 

screening colonoscopy of 2.5 per 1,000 procedures, with 85 percent of the complications 

occurring in patients who had had a polypectomy.95 

Misuse of colonoscopy also includes lack of detection of important lesions. Studies have 

found that from 2.1 percent to 5.9 percent of people diagnosed with CRC had had a colonoscopy 

within 3 years of the cancer diagnosis,96-98 raising the issue of missed cancers. One study of 

back-to-back colonoscopies done on the same day found that 6 percent of adenomas at least 1 cm 

in size and 13 percent of adenomas 6 to 9 mm in size were missed on the first colonoscopy.99 

Other studies of CRC found by short-term follow-up colonoscopy after previous colonoscopy 

have raised the same question.81,100 

One variable that has been studied to provide insight into important missed lesions at 

colonoscopy is the adenoma detection rate. Several studies have shown variation among 

endoscopists in this rate. One factor associated with adenoma detection rates at colonoscopy is 

withdrawal time, which is the time required for the endoscopist to withdraw the colonoscope 

after full insertion.101-103 Although longer withdrawal times are associated with increased 

detection of advanced adenomas (i.e., adenomas greater than 1 cm in size, or with dysplastic or 

villous components), longer times are also associated with increased detection and removal of 

small, low-risk polyps of uncertain clinical importance. A follow-up study found that instituting 

a practice-wide policy of at least 8 minutes for withdrawal reduced variation in adenoma 

detection rates among endoscopists; specifically the new policy increased detection of any 

neoplasia from 23.5 percent to 34.7 percent and increased detection of advanced adenomas from 

5.5 percent to 6.3 percent of subjects.104 Thus, most of the increase in adenoma detection was 

due to detection of nonadvanced adenomas. 

Another factor associated with lower adenoma detection rates is depth of insertion, in 

particular the percentage of colonoscopies in which the cecum was reached. One study used an 

Ontario, Canada, database to explore the percentage of colonoscopies that were coded as 

incomplete (i.e., did not reach the cecum), finding variation in incomplete rates.105 

Colonoscopies performed in a clinician’s office were more likely to be incomplete than ones 

performed in an academic center (24.6 percent versus 12.6 percent). The percentage of 

incomplete colonoscopies declined over time (18.9 percent in 1999 to 10 percent in 2003). 

Similar data are not available from the United States. 

Summary 

National surveys show that CRC screening rates have been slowly increasing since 2000, 

reaching 50 percent to 60 percent in 2006. Screening rates in medical practices are also at about 

the same level. There are disparities in screening between white people and other racial and 

ethnic groups; Hispanic people have some of the lowest screening rates. Low income, low 

35 
educational level, and lack of health insurance are also associated with lower screening rates. 

States vary greatly in CRC screening rates. 

The increase in CRC screening since 2001 has come primarily from increasing rates of 

colonoscopy; use of FS and FOBT has declined. This national trend toward increased 

colonoscopy and reduced FOBT is different than trends within the US VA program and in other 

countries, where FOBT remains the most common screening test. 

In addition to underuse of CRC screening, good evidence suggests underuse of adequate 

discussions about CRC screening. For some patients, discussions do not provide comparative 

information about the benefits and risks of alternative strategies or do not allow patient 

participation in decisionmaking. For other patients, likely no discussion with their clinicians 

takes place at all. 

In addition to the evidence of underuse of CRC screening and discussion is evidence of 

overuse. Some people are screened who have severe comorbidities and are unlikely to benefit. 

Older people above an age at which benefits are limited are also likely being screened. 

Surveillance colonoscopy after polypectomy is probably also occurring too frequently, thus 

reducing capacity for screening colonoscopy and increasing discomfort, inconvenience, and risk 

for many people. 

Misuse of screening is also a problem. Some people receiving in-office rather than home 

FOBT, others not returning FOBT cards, and people with positive FOBTs not getting appropriate 

followup. Few health plans have systems for monitoring and improving these problems. Misuse 

of colonoscopy occurs because adverse events occur (e.g., bleeding or colonic perforation) and 

because endoscopists miss important lesions (and perhaps find and remove unimportant lesions). 

36 
Chapter 4. Results 

This chapter presents the results of our evidence review for the following four key questions 

(KQs): KQ 2, factors associated with colorectal cancer (CRC) screening; KQ 3, interventions 

that have been tested to increase CRC screening; KQ 4, current capacity in the United States to 

increase CRC screening; and KQ 5, methods for tracking and monitoring the use and quality of 

CRC screening. As noted in Chapter 2, we identified 3,029 citations from our searches 

(Appendix A).†† Figure 2 documents the disposition of articles for the review. Working from 861 

articles retrieved for full text review, we included 139 for background and excluded 571 at this 

stage. A total of 72 studies (74 articles) qualified for inclusion for KQ 2, 21 studies (22 articles) 

for KQ 3, 12 studies for KQ 4 and 8 studies for KQ 5. 

Appendix C-1 provides the detailed 

evidence tables for KQs 1, 2, and 3. 

Appendixes C-2 and C-3 present 

individual quality ratings for randomized 

clinical trials (RCTs) and observational 

studies, respectively. Appendix C-3 

provides detailed abstractions for KQ 4. 

Appendix C-4 provides detailed 

abstractions for KQ 5. Evidence tables for 

each key question are presented in 

alphabetical order by last name of the first 

author. 

As noted in earlier chapters, an overall 

assessment of the CRC screening and 

related factors requires evaluation of 

sources of heterogeneity, including 

clinical context, population served, and 

for the randomized control trials (RCT), 

the type of comparator. CRC screening is 

conducted in a variety of clinical contexts 

and assessed through the completion of 

one or several tests (i.e., fecal occult 

blood test (FOBT), done at home or in the 

office, and/or some type of endoscopy 

(i.e., flexible sigmoidoscopy [FS], 

colonoscopy, or double contrast barium 

enema [DCBE]). Most studies we 

assessed measured the outcome of 

screening by completion of a FOBT at 

home, and included one or more of these 

endoscopy tests. However, since national 

guidelines about which tests should be 

Figure 2. Quorum tree/disposition of articles 

Titles and abstracts identified 

through searches 

n = 3,029 

Citations excluded 

n = 2,165 

Articles published as abstract-only 

n = 3 

Full-text articles retrieved 

n = 861 

Full text articles excluded: 

n = 571 

110 Study not conducted in US 

155 No original research/analysis 

25 Wrong population/setting 

104 Wrong outcomes 

50 Wrong study design 

86 Does not address/answer a KQ 

40 Data collection prior to 1998 

1 Published too late for inclusion 

Background articles 

n = 139 

Poor quality 

n = 37 

Articles included in 

this review* 

n = 116 

KQ2 = 74 

KQ3 = 22 

KQ4 = 12 

KQ5 = 8 

*Articles were included 

for more than one KQ 

used and when have been altered several times over the period of time for which we were 

†† Appendixes and evidence tables cited in this report are available at 

http://www.ahrq.gov/downloads/pub/evidence/pdf/crcuse/crcuse.pdf. 

37 
reviewing studies (i.e., 1998-present day), the assessment of screening rates has also changed 

over time and is somewhat problematic to analyze. For the studies assessed under KQs 2, 3, and 

4, there is a strong reliance on self-reported screening rates, with fewer studies incorporating 

claims data analysis in the assessment of CRC screening. 

An additional source of heterogeneity is the type of studies conducted for each type of KQ 

and the descriptive or analytic nature of the literature. For KQ 2, we found the largest number of 

studies but all are based on observational data, primarily collected retrospectively through crosssectional or cohort designs. Because of the extensive variables explored in relation to CRC 

screening, we present the findings for this KQ in much less detail than the other KQs, focusing 

on the study characteristics and overall results specific to each type of factor that may be 

associated with screening. 

This literature is characterized by a few articles together constituting a single study. We refer 

to studies in the text and cite all relevant articles for each study; article and study counts, 

therefore, frequently do not match. Our summary tables below feature groups of studies 

organized by the factors that may be associated with CRC screening (KQ 2), the different types 

of interventions that have been tested to increase screening (KQ 3), or the types of studies that 

have been done to assess capacity for screening (KQ 4) and monitoring of use and quality of 

screening (KQ 5). We have organized the studies in each summary table such that those rated as 

good quality are listed first and organized alphabetically by the first author’s last name, followed 

by fair quality studies organized in the same way. The summary tables also provide information 

to identify the study (author, and date of publication), study design, population and setting, 

sample size, study quality, intervention (when relevant), comparators, and results. 

KQ 2: What Factors Influence the Use of Colorectal Cancer 

Screening? 

Key question (KQ) 2 focuses on the factors that are associated with the use of CRC 

screening. These factors can relate to either patient or provider characteristics and to the 

interaction between the provider and patient. Other factors that could be associated with the use 

of CRC screening may be system-level characteristics, such as involvement of nonclinician staff 

in screening, use of reminder or recall systems, having an organized referral system, or the size 

or type of the medical practice. 

We identified a total of 72 studies (74 articles) rated good or fair quality that examined 

different factors that are associated with the use of CRC screening1-2,21,42,46,55-57,65-66,88,106-168 rated 

good or fair quality. For these studies, we categorized the factors into five topic areas: 1) patient 

level factors that influence CRC screening; 2) physician factors (physician characteristics, 

physician-patient connectedness, and physician recommendations); 3) patient and physician 

communication; 4) periodic health exams or annual checkups; and 5) system level factors that 

may be associated with screening rates. We also identified two articles that focused on patient 

level predictors of followup among patients who have received a positive FOBT result and 

present them separately under the patient factors section of this chapter.88,168 

Studies for this KQ are presented somewhat differently than those for the other KQs. 

Because of the vast number of studies this section includes, we start by presenting findings from 

three nationally representative samples of respondents where the investigators present overall 

findings that are not stratified by some factor (e.g., race, sex). For these three studies,21,46,151 we 

present the absolute screening rates in order to provide benchmarks for assessing how screening 

rates change when other factors are presented separately in the remainder of this section. We 

38 
then present the results of the four primary patient characteristics of demographics, access to 

care, personal health or risk factors, and psychosocial factors that are associated with CRC 

screening. For each of these characteristics, we then summarize the findings from the three 

national studies and present adjusted odds ratios (AOR) and other statistics as appropriate. After 

presentation of the three national ‘overview’ studies, we follow that section with all additional 

studies that present findings for each of the seven topic areas that may be associated with 

screening. In each of these sections, we provide summary tables of the key studies that examined 

the corresponding factor. In each table, we also present the overarching results by using the 

symbols of “↑” or “↓” to provide a quick assessment of each study’s findings specific to the key 

variables and the outcome of CRC screening (i.e., the “↑” means there is a positive association 

between the variable and CRC screening, and the “↓” means there is a negative association). 

Because this KQ includes so many studies, we think the use of these symbols helps the reader to 

understand what the overall results convey. Since this KQ presents descriptive findings from 

observational studies, we have not provided an assessment of the strength of evidence here. 

The following presents the study characteristics and overview of results for each of the seven 

topic areas potentially associated with CRC screening. 

Patient Factors: Overview 

The majority of studies that have examined factors that predict the likelihood of CRC 

screening have focused on patient characteristics. We identified a total of 56 studies that we rated 

as good or fair quality that reported findings related to this topic.1-2,21,42,46,55-56,65,106-109,111-126,128­

134,136-138,141,144-147,149-151,155-158,160-163,165-166 that we rated as good or fair quality that reported 

findings related to this topic. We also included two studies that examined patient level factors 

that predict followup after a positive FOBT result.88,168 

For patient factors, we categorized studies into four primary topics: 

•	 patient demographics: studies that explore the relationship between characteristics such as 

age, sex, income, insurance status, race, ethnicity, and acculturation and the completion of 

various CRC screening tests. 

•	 access to care: studies that explore the impact on CRC screening rates of having a regular 

source of care, recently visiting a provider at least once, and proximity to health care 

facilities. 

•	 personal health or risk factors: studies that focus on the relationship of health factors (e.g., 

health status, obesity) or healthy behaviors (e.g., obtaining screenings for other cancers); 

or risk factors (e.g., family history of CRC, personal history of other cancers) or risky 

health behaviors (e.g., smoking, sedentary lifestyle, alcohol use) to the outcome of CRC 

screening by any test. 

•	 psychosocial factors: studies on patient knowledge, attitudes, beliefs, and perceptions 

related to either CRC or screening for that type of cancer. 

All the studies for KQ 2 present observational data collected either through surveys of selfreported screening rates or through analysis of claims data. These studies include those that 

report on national, state, regional, and local samples of respondents or patients. These studies 

yield a broad array of findings in a variety of populations and examine a large number of patient 

factors and their relationship to CRC screening; dealing with all of them simultaneously risks 

presenting an unnecessarily complex synthesis. For that reason, we have adopted an analytic 

strategy for this KQ in which we initially describe the three studies that have the most nationally 

representative samples and that did not stratify their results by any factors (e.g., race, 

39 
ethnicity).21,46,151 In our view, these studies provide a broad overview of the issues and findings 

and provide a robust basis for then analyzing studies with a narrower focus. 

Patient Factors: Three Nationally Representative Studies 

Overview of national studies of patient characteristics. Study characteristics. Three 

studies examined the overall patient characteristics that seem to predict CRC screening in a 

national sample.21,46,151 We rated all three studies as good quality. All relied on national survey 

data for their analysis; specifically, all used National Health Interview Survey (NHIS) data, with 

two presenting findings from 200021,151 and one from 2005.46 All three presented findings for 

respondents ages 50 or older.21,46,151 All three explicitly excluded from their analysis people 

reporting a prior diagnosis of CRC.21,46,151 

The studies varied slightly on how they assessed the outcome of CRC screening. Two studies 

used the same definition (that respondents who reported an FOBT within the past year or an 

endoscopy within the past 10 years were adherent with national screening guidelines).21,46 The 

remaining study defined adherence to screening as obtaining an FOBT in the past year, an 

endoscopy within the past 10 years, or both, for screening purposes. They defined this variable as 

“time-screening adherence” and included those who reported being screened as part of a routine 

physical examination, because of a specific problem, as a followup to another screening test, or 

because of family history of CRC.151 

Overview of results. For the three studies, we present the overall findings for each of the 

categories of patient characteristics that may influence screening rates: demographics, access to 

care, personal health or risk factors, and psychosocial factors (Table 6). For each set of findings, 

we present only those screening rates or adjusted odds ratios (AORs, with 95 percent confidence 

intervals or significance levels) specific to being current with any CRC test (per the authors’ 

computation of their outcomes variables); we do not present findings for specific tests in this 

section unless the authors limited their measurement of CRC screening to only one or two tests. 

“Significant” in this discussion means statistically significant at least a P = 0.05 level. 

Table 6. Overall findings from the three national studies for each category of patient characteristics 

Patient 

Characteristic Overall Findings 

Patient demographics 

Age All 3 studies reported that CRC screening rates increase for each age group, until the older age 

range (≥ 75 for 1 study151 and ≥ 80 for the other 2 studies21,46), at which point screening rates 

appear to decline slightly. 

Sex Findings from both studies of 2000 NHIS data indicated that females were slightly less likely to 

be screened than males (AOR, 1.16 of males compared with female; 95% CI, 1.03-1.31151 and 

AOR, 0.89 of females compared with male; 95% CI, 0.80-0.9921). By 2005, screening rates did 

not differ on this variable.46 

AOR, adjusted odds ratio; CI, confidence interval; CRC, colorectal cancer; NHIS, National Health Interview Survey. 

40 
Table 6. Overall findings from the three national studies for each category of patient characteristics 

(continued) 

Patient 

Characteristic Overall Findings 

Race Blacks and whites did not differ significantly in adjusted screening rates in any of the three 

studies, though they did in absolute rates.21,46,151 When the race category of “other” was 

included, 1 study reported that this group was less likely to be screened when compared with 

whites (AOR, 0.67; 95% CI, 0.50-0.9221); another study found no difference in screening rates in 

the “other” race group compared with whites.46 

Ethnicity	 Hispanics were less likely to report being screened than non-Hispanic whites in 1 study using 

2000 NHIS data (AOR, 0.73; 95% CI, 0.58-0.92),151 but the other 2 studies had no significant 

differences for this factor (after adjustment). One study reported a nonstatistically significant 

trend that Asians were less likely than whites to report being screened (41.7% and 50.0%, 

respectively; P = 0.07).46 

Income Only 2 studies reported findings by income. One reported a significant difference in screening 

rates between respondents living in higher income households and those in lower income 

households (a 45.5% screening rate for those reporting an income < $20,000 and a 53.2% 

screening rate for those with incomes at or above $75,000; P = 0.006).46 

Insurance All 3 studies reported findings based on whether respondents had health insurance or not. Each 

demonstrated that persons with no insurance were significantly less likely to report being 

screened than those who had any type of insurance (10.1% to 24.1% of those with no insurance 

had been screened compared with 40% to 68.2% of those with insurance).21,46,151 

Other factors All 3 studies reported findings indicating that subjects with higher education and those who were 

(education level married were more likely to have completed CRC screening.21,46,151 

and marital status) 

Access to care 

Access to care	 Both having a usual source of care and visiting that provider at least once in the past year were 

consistently associated with CRC screening.21,46,151 

Personal health or risk factors 

Personal health/ Family history of cancer, particularly CRC; personal history of another (non-CRC) cancer; use of 

risk factors other cancer screening (i.e., mammogram, Pap test); and never or former smokers were 

positively associated with CRC screening in all three studies.21,46,151 General health status, 

alcohol use, and obesity may be variables associated with screening but the findings were less 

consistent. 

Psychosocial factors 

Psychosocial The most common reason for not being screened (either “ever” or “within the recommended time 

factors period”) is that the respondent “never thought about it.”21,46 

Other findings 

Other findings The 3 studies also reported findings that are not presented here because they were not found to 

be associated with CRC screening or were not reported across all 3 studies. One study reported 

the association between metropolitan statistical areas and screening rates and found no 

relationship.151 The same study also reported screening rates by region of the country and found 

that those living in any areas other than the West were less likely to report current screening 

(AOR, range 0.79-0.82).151 

Demographics. All three studies examined demographic characteristics, including age, sex, 

income, insurance status, race, ethnicity, acculturation, and other factors such as education and 

marital status. The adjusted screening rates reported for each study appear in Table 7. We then 

discuss the factors that one or more of the three studies reported as predictors of CRC screening 

rates. None of these studies adjusted for or reported findings for factors related to acculturation 

(i.e., English-language proficiency, foreign birth, years living in United States). 

Age. For the three studies,21,46,151 screening rates gradually increased for each age group from
 

the age groups from 50 to 70 years. One study using 2000 NHIS data found that older patients 

were more likely to be screened than younger patients. Relative to the referent group (50-54 

years), respondents 55-59 years of age were slightly more likely to report being screened (AOR, 

41 
Table 7. Adjusted CRC screening rates by key patient-level demographic characteristics, for three national 

studies 

Ata et al., 2006151 

2000 NHIS* 

Seeff et al., 200421 

2000 NHIS† 

Shapiro et al., 

200846 

2005 NHIS‡ 

Demographic Characteristics % (95% CI) % (95% CI) % (95% CI) 

Overall screening rates 

 Home FOBT within past year 15.1 (14.3-15.9) 17.1 (16.2-17.9) 12.0 (11.3–12.7) 

 Endoscopy within past 10 years 17.6 (16.8-18.4) 33.9 (32.9-35.0) 45.2 (44.0-46.4)

 Either test within recommended time 25.8 (24.9-26.7) 42.5 (41.4-43.5) 50.0 (48.8-51.2) 

Age 

50-54 19.7 (17.9-21.7) 35.3 (33.9-37.2) 40.4 (38.7-42.1)

 55-59 25.6 (23.3-27.9) 

60-64 26.7 (24.4-29.1) 45.9 (43.8-48.0) 56.5 (54.3-58.6)

 65-69 30.9 (28.5-33.5) 

70-74 30.5 (27.9-33.3) 52.3 (50.1-54.5) 60.2 (58.0-62.3)

 75-79 26.5 (24.4-28.6) 

80+ 40.7 (37.6-43.9) 50.3 (47.2-53.4) 

Sex

 Female 23.9 (22.8-25.1) 41.0 (39.7-42.4) 48.7 (47.1-50.3)

 Males 28.0 (26.6-29.5) 44.5 (42.9-46.1) 51.7 (49.9-53.4) 

Married and living with partner 28.7 (27.4-30.0) 46.3 (44.9-47.7) 53.2 (51.6-54.7) 

All others 20.9 (19.8-22.1) 36.6 (35.0-38.1) 44.4 (42.8-46.0) 

Education 

 < High school 17.8 (16.3-19.3) 31.4 (29.5-33.3) 37.0 (34.6-39.6)

 High school 24.0 (22.4-25.6) 40.2 (38.3-42.0) 46.9 (44.8-49.0)

 Some college 27.0 (24.8-29.4) 46.2 (44.1-48.3) 54.2 (52.3-56.2)

 College graduate 32.6 (30.2-35.2) 54.0 (51.5-56.5) 60.7 (58.7-62.6)

 Post-graduate 38.4 (35.2-41.7) -- --

Race 

 Non-Hispanic whites 27.3 (26.3-28.3) 43.6 (42.5-44.7) 51.1 (49.8-52.4)

 Non-Hispanic blacks 22.7 (20.1-25.6) 37.8 (34.9-40.7) 43.5 (40.6-46.5) 

Other -- 28.7 (24.5-33.0) 38.2 (27.7-49.8) 

Ethnicity

 Hispanic 15.8 (13.5-18.5) 29.9 (26.4-33.3) 34.2 (30.6-37.9)

 Asian -- -- 38.7 (32.8-44.9) 

Annual household income 

 <$20,000 19.6 (18.1-21.1) 35.2 (33.0-37.3) 37.4 (35.4-39.5)

 $20,000- 34,999 25.6 (23.6-27.6) 41.1 (38.4-43.7) 47.5 (45.1-49.9)

 $35,000- 44,999 25.1 (22.1-28.0) -- --

 $35,000- 54,999 -- 44.1 (41.0-47.3) 50.1 (47.2-53.1)

 $45,000- 65,000 27.5 (24.7-30.2) -- --

 $55,000- 74,999 -- 46.6 (42.0-51.2) 54.4 (50.9-57.9) 

≥$65,000 31.8 (29.7-33.9) -- --

≥$75,000 -- 56.6 (52.8-60.3) 58.5 (55.3-61.7) 

Insurance status 

 No (none) 10.1 (8.0-12.6) 18.1 (11.2-24.9) 24.1 (19.2-29.7)

 Yes (coverage of some type) 27.0 (26.1-28.0) -- --

 Private only -- 44.4 (41.0-47.8) 48.7 (45.9-51.5)

 Medicare only -- 40.0 (34.8-45.1) 44.6 (39.0-50.3)

 Medicare + private/Medigap -- 50.1 (44.4-55.8) 58.1 (50.7-65.2)

 Medicare + Medicaid -- -- 45.1 (38.7-51.6)

 Medicaid only -- -- 27.6 (21.1-35.2) 

42 
Table 7. Adjusted CRC screening rates by key patient-level demographic characteristics, for three national 

studies (continued) 

Ata et al., 2006151 

2000 NHIS* 

Seeff et al., 200421 

2000 NHIS† 

Shapiro et al., 

200846 

2005 NHIS‡ 

Demographic Characteristics % (95% CI) % (95% CI) % (95% CI) 

 Military -- -- 68.2 (63.8-72.4)

 Other/multiple carriers -- 37.8 (34.4-41.2) 49.7 (42.8-56.6) 

CI, confidence interval; CRC, colorectal cancer; FOBT, fecal occult blood test; NHIS, National Health Interview Survey; ‘--‘, data not reported 

for corresponding range of responses. 

* Multivariate adjustments were made for all independent variables in their analysis. †

 Adjusted for all other variables in their analysis except for mammography and Pap test use. 

‡

 Adjusted using predictive margins for all other characteristics in their analysis. 

1.51; 95% CI, 1.24-1.84),151 as were those 60-64 years (AOR, 1.41; 95% CI, 1.41-2.05)151 and 

even more so for those 65-69 (AOR, 2.14; 95% CI, 1.75-2.62) and 70-74 (AOR, 2.20; 95% CI, 

1.80-2.70).151 The other study using 2000 NHIS data reported the same trend (compared with 

subjects 50-59 years, AOR 1.45; 95% CI, 1.26-1.67 for those 60-69 years and AOR, 1.69; 95% 

CI, 1.41-2.03 for those 70-7921). The study using 2005 NHIS data showed a similar trend and 

presented findings as age-adjusted percentages; 42.6 percent of those 50-59 years of age (95% 

CI, 40.4-44.8 percent), 56.6 percent of those 60-69 years (95% CI, 54.4-58.7 percent); and 57.2 

percent of those 70-79 years (95% CI, 54.5-59.9 percent) reported being screened for CRC.46 

In all three studies, however, screening rates were lower for the oldest category of patients 

relative to the adjacent age group;21,46,151 the two 2000 NHIS studies reported an AOR of 2.08 for 

those 75 years of age and older (95% CI, 1.70-2.53)151 and AOR of 1.25 for those 80 years and 

older (95% CI, 1.01-1.56).21 The study of 2005 NHIS data showed a similar trend: 49.9 percent 

of respondents 80 years or more years of age reported being current with CRC screening (95% 

CI, 46.1-53.8 percent). 

Sex. For the two studies of 2000 NHIS data, the reported screening rate was slightly lower 

among females than male.21,151 In one, males were more likely to report screening than females 

(AOR, 1.16; 95% CI, 1.03-1.31),151 and in the other females were less likely to report being 

screened (AOR, 0.89; 95% CI, 0.80-0.99).21 The study of 2005 NHIS data found no difference 

between screening rates of males (49.2 percent; 95% CI, 47.4-50.9) and females (50.4 percent; 

95% CI, 48.7-52.2; P = 0.29).46 For the two studies that presented screening rates for FOBT 

within the past year or endoscopy within the past 10 years, one reported no difference in FOBT 

or endoscopy screening rates among males and female,46 and the other found similar screening 

rates for FOBT and only a slightly lower rate of endoscopy screening for females compared with 

males (AOR, 0.77; 95% CI, 0.69-0.86).21 

Race. Comparisons are more challenging for the reports of CRC screening by race because 

the three studies reported the findings somewhat differently. All three studies reported findings 

for whites and blacks; all three reported adjusted rates that show no difference between blacks 

and whites.21,46,151 In the two studies of 2000 NHIS data, blacks had a slightly nonstatistically 

higher odds ratio but not a statistically significant different rate of CRC screening than whites (as 

the referent group for both studies).21,151 One study also reported CRC screening for the race 

category of “other,” which could include Asians, American Indians, and others; it found that this 

group was less likely to report being screened than whites (AOR, 0.67; 95% CI, 0.50-0.92).21 

Another study also reported a current screening rate of 40.3 percent (95% CI, 27.7-54.4; 

P = 0.07) for subjects in the “other” race category.46 

Ethnicity. All three studies provided CRC screening rates for Hispanics. One study reported 

that Hispanics were statistically less likely than whites to be screened for CRC (AOR, 0.73; 95% 

43 
CI, 0.58-0.92);151 the other two studies showed that there was no statistically significant 

difference between Hispanics and “non-Hispanic” whites (AOR, 0.92; 95% CI, 0.75-1.1221 for 

Hispanics with whites as the referent group; and adjusted percentage of 45.9% for Hispanics; 

95% CI, 41.7-50.2%; compared with 50.2% for non-Hispanic whites; P = 0.0646). 

We have included Asians in our discussion of ethnicity throughout this chapter; in places, we 

present study findings specific to subgroups of Asians (Chinese, Japanese, Korean, 

Vietnamese).46 One study reported findings specific to Asians: the percentage reporting being 

screened was lower than the figure for whites (41.7 percent and 50.0 percent, respectively; 

P = 0.07).46 

In terms of the combination of racial/ethnic differences, one study highlighted unadjusted 

and adjusted screening rates for Hispanics and blacks,151 whites had the highest and Hispanics 

had the lowest proportions of adherence to timely screening. Compared with whites, Hispanics 

were 50 percent (P < 0.001) less likely to be adherent, and blacks approximately 23 percent 

(P < 0.01) less likely to be adherent. After multivariate adjustment (for all independent variables 

in their analysis), the difference between blacks and whites disappeared (AOR, 1.13; 95% CI, 

0.95-1.35) but remained statistically significant for Hispanics (AOR, 0.73; 95% CI, 0.58­

0.92).151 The other two studies reported similar findings in the unadjusted and adjusted rates for 

the different racial and ethnic groups.21,46 In one study, race was no longer a predictor of FOBT 

use when the rates were adjusted;21 in another, adjustment for all the other factors in their 

analysis weakened the association between screening and Hispanic ethnicity (45.9 percent for 

Hispanics and 50.2 percent for non-Hispanics; P = 0.06).46 

Annual household income. Two studies reported findings based on annual household 

income,46,151 using slightly different income categories. Using the annual household income 

group of $20,000 or more as a referent, one study found that each higher income group was 

slightly more likely to report being screened; the group reporting an income of $65,000 or more 

was among those most likely to report being screened (AOR, 1.28; 95% CI, 1.04-1.58).151 In 

another study, screening rates differed significantly between low-income and high-income 

groups: 45.5 percent screening rate for those < $20,000, and 53.2 percent screening rate for those 

≥ $75,000 (P = 0.006).46 

Insurance status. All three studies reported findings based on whether respondents had health 

insurance; and all demonstrated that those with no insurance were statistically significantly less 

likely to report being screened than those who had any type of insurance.21,46,151 Using those 

without insurance as the referent group, both studies of 2000 NHIS data reported those with any 

insurance were more likely to report being screened than those without (AOR, 1.42; 95% CI, 

1.05-1.93151 and AOR, ranges 1.66-1.93, with statistically significant 95% CIs21). The study of 

2005 NHIS data demonstrated a similar finding; 31.6 percent of those without insurance versus 

43.0 percent to 67.9 percent of those in other insurance categories reported screening 

(P < 0.0001). 

Two studies reported screening by type of insurance. For 2000 among those with any 

insurance, those with private insurance were the least likely to be screened (AOR, 1.66; 95% CI, 

1.28-2.15) and those with a combination of private insurance and Medicare or Medigap were the 

most likely to be screened (AOR, 1.93; 95% CI, 1.44-2.59).21 For 2005 among those with any 

insurance, those with Medicaid were the least likely with insurance to report being screened 

(43.0 percent; 95% CI, 35.7-50.6) and those from the military were the most likely to be 

screened (67.9 percent; 95% CI, 63.3-72.1).46 

Other factors: Education level and marital status. Education level and marital status 

consistently reported as associated with CRC screening. All three studies reported that 

respondents with lower levels of education had lower levels of CRC screening than better 

44 
educated groups. For 2000, both studies reported that those who finished high school or had any 

education beyond that level were more likely than those who did not complete high school to 

report being screened (AOR, range 1.27-2.08 with “less than high school” as the referent 

group;151 AOR, range 1.27-1.83 with “less than 12 years” as referent group21). For 2005, 

reported a similar trend; rates of CRC screening increased as education levels rose (ranging from 

47.9 percent to 55.5 percent compared with 43.8 percent for those with less than 12 years of 

education; P = 0.01).46 

With respect to marital status, all studies reported that being married was associated with 

CRC screening.21,46,151 

Access to care. Access to care is a patient-level characteristic that many studies in our 

review examined. These three studies each reported two measures of access to care—whether an 

individual has a “usual (or, regular) source of care” and the frequency or recency of contact with 

the provider (i.e., number of visits in past year or time since the last visit).21,46,151 Table 8 

provides the adjusted rates for variables related to access to care. 

Table 8. Adjusted CRC screening rates by patient-level variables of access to care for three national studies 

Access to Care Variables at Ata et al., 2006151 Seeff et al., 200421 Shapiro et al., 200846 

the Patient Level 2000 NHIS* 2000 NHIS† 2005 NHIS‡ 

% (95% CI) % (95% CI) % (95% CI) 

Access to care 

Usual source of care 

Yes 27.0 (26.1-28.0) 44.2 (43.2-45.3) 51.9 (50.7-53.1)

 No 10.1 (8.0-12.6) 17.8 (14.9-20.8) 24.7 (20.8-29.0) 

Number of physician visits in 

past years 

None -- 14.8 (12.6-17.0) 19.5 (16.8-22.5)

 1 -- 36.2 (33.3-39.1) 40.2 (37.3-43.2)

 2-5 -- 44.6 (43.0-46.3) 52.5 (50.7-54.3) 

≥6 -- 51.7 (49.9-53.5) 59.8 (58.0-61.6) 

Time since last doctor visit 

≤ 6 months 28.9 (27.8-30.0) -- --

 > 6 months-1 year 22.9 (20.3-25.8) -- --

 >1-2 years 11.2 (8.4-14.7) -- --

 >2 years 3.7 (2.3-5.9) -- --

CI, confidence interval; CRC, colorectal cancer; NHIS, National Health Interview Survey; ‘--‘, data not reported for corresponding range of 

responses 

* Multivariate adjustments were made for all independent variables in their analysis. †

 Adjusted for all other variables in their analysis except for mammography and Pap test use. 

‡

 Adjusted using predictive margins for all other characteristics in their analysis. 

Usual source of care. All three studies found that those respondents who reported having a 

usual source of care were more likely to obtain CRC screening than those who did not have a 

usual source of care.21,46,151 The two studies of 2000 NHIS data each reported significant 

differences in rates of CRC screening between those who had a usual source of care and those 

who did not (AOR, 1.61; 95% CI, 1.17-2.21151 and AOR 1.65; 95% CI, 1.30-2.09).21 For 2005, 

findings for adjusted rates were similar; 51.0 percent of those with a usual source of care (95% 

CI, 49.7-52.3%) and 30.5 percent of those without a usual source of care (95% CI, 26.5-34.8%; 

P = 0.0001) were screened.46 

Frequency or recency of visits to physician. All three studies provided similar findings: those 

who had visited a physician more frequently in the past year or had seen a doctor more recently 

were more likely to report being screened for CRC.21,46,151 In one study, those with no physician 

visits in the past year were significantly less likely to obtain screening than those who visited a 

physician at least once (AOR, range 2.40-4.68).21 In another, those who had visited a physician 

within the past 1 to 2 years were less likely to have had a CRC screening test than those who had 

45 
visited within the past 6 months (AOR, range 2.76-7.59 with less than 2 years as the referent 

group).151 The third study did not report adjusted rates for this variable; unadjusted rates appear 

in Table 8.46 

Personal health factors and risk factors. Personal health factors are defined as 

characteristics from respondents’ family history or personal health history (e.g., prior polyp 

removal, screening behavior with regard to other cancers, general health status, family CRC 

diagnosis) that would place them at increased risk for CRC or that may be related to healthy 

behaviors that could influence the extent to which they obtain regular CRC screenings. Risk 

factors for health problems that may be related to CRC screening include smoking, sedentary 

lifestyle, poor eating habits, obesity, and any factor that may place a person at increased risk for 

developing CRC. Table 9 presents the absolute rates of these variables as reported by the three 

national studies, followed by a discussion of findings for each.21,46,151 

Table 9. Adjusted CRC screening rates by patient-level personal health or risk factors for three national 

studies 

Ata et al., 2006151 

2000 NHIS† 

Health or Risk Factors % (95% CI) 

Family history of CRC 

Yes 30.6 (29.3-32.0)* 

No 23.8 (22.4-25.3) 

Personal history of cancer 

Yes 32.3 (29.6-35.0) 

No 24.9 (24.0-25.9) 

General health status 

Seeff et al., 200421 

2000 NHIS‡ 

% (95% CI) 

59.7 (56.5-62.8)

41.4 (40.2-42.5)

55.1 (51.8-58.3)

40.6 (39.5-41.7)

Shapiro et al., 200846 

2005 NHIS§ 

% (95% CI) 

 68.3 (64.9-71.5)

 48.8 (47.6-50.1) 

 63.9 (61.0-66.8)

 47.8 (46.5-49.0) 

 Excellent 30.1 (21.8-32.1) -- --

 Very good 27.7 (26.1-29.4) -- --

 Excellent/good -- 42.6 (41.4-43.8) --

 Excellent/very good/good -- 50.5 (49.1-51.9)

 Good 24.6 (23.0-26.3) -- --

 Fair 21.1 (19.1-23.4) -- --

 Fair/poor -- 42.4 (40.1-44.7) 48.1 (45.7-50.4)

 Poor 20.1 (17.2-23.3) -- --

Body mass index (kg/m2

) 

 Underweight 17.6 (13.3-22.8)

 Normal (<25) 25.5 (24.0-27.0) 40.5 (38.7-42.2) 

49.1 (47.1-51.0)

 Overweight (25-29) 27.6 (26.1-29.2) 43.6 (41.9-45.3) 51.2 (49.4-52.9)

 Obese (≥30) 26.6 (24.7-28.5) 44.3 (42.1-46.5) 50.5 (48.4-52.7) 

46 
Table 9. Adjusted CRC screening rates by patient-level personal health or risk factors for three national 

studies (continued) 

Ata et al., 

Health or Risk Factors 

2006151 

2000 NHIS 

Seeff et al., 200421 

2000 NHIS 

Shapiro et al., 200846 

2005 NHIS 

% (95% CI) % (95% CI) % (95% CI) 

Mammogram within 2 years 

No -- 19.1 (17.0-21.2) 24.0 (21.7-26.5)

 Yes -- 49.2 (47.6-50.9) 60.6 (58.7-62.4) 

Pap test within 3 years 

No -- 24.1 (21.6-26.7) 33.3 (31.0-35.8)

 Yes -- 46.8 (45.2-48.3) 56.0 (54.0-57.9) 

Physical activity

 None 20.5 (19.3-21.7) 35.3 (33.8-36.7) 41.9 (40.3-43.5)

 Moderate/some/irregular 29.6 (27.6-31.6) 44.7 (42.3-47.1) 55.3 (52.9-57.6)

 Regular or meet/exceed 33.3 (31.3-35.5) 51.2 (49.2-53.3) 57.6 (55.9-59.7) 

recommendations 

Smoking status 

 Never/nonsmokers 25.1 (23.8-26.5) 41.3 (39.8-42.9) 49.2 (47.6-50.7)

 Former/quitters 30.9 (29.3-32.6) 48.2 (46.5-49.9) 56.0 (54.2-57.9)

 Current/smokers 18.2 (16.3-20.3) 35.3 (32.6-38.0) 37.8 (34.9-40.8) 

Alcohol use 

None -- 38.6 (37.2-40.0) 43.4 (41.7-45.0)

 1-14 drinks/week -- 47.2 (45.8-48.7) 56.8 (55.2-58.4) 

≥ 14 drinks/week -- 43.7 (39.0-48.5) 53.0 (48.7-57.2) 

CI, confidence interval; CRC, colorectal cancer; NHIS, National Health Interview Survey; ‘--‘, data not reported for corresponding range of 

responses. 

* For this study, findings reported were for “family cancer history” not specific to CRC.151 

† Multivariate adjustments were made for all independent variables in their analysis. 

‡

 Adjusted for all other variables in their analysis except for mammography and Pap test use. 

§ Adjusted using predictive margins for all other characteristics in their analysis. 

Health factors. Family history of CRC or other cancer, personal history of other non-CRC 

cancers, and use of mammograms or Pap tests were all found to be consistently associated with 

CRC screening rates.21,46,151 One study used “family cancer history” that was not specific to 

CRC; those who reported this as part of their history were significantly different from those who 

did not (AOR, 1.27; 95% CI, 1.13-1.43). Findings in another study were specific to a family 

history of CRC and reported a stronger association between screening rates; those with a family 

history were more than twice as likely to report being screened as those who had none (AOR, 

2.04; 95% CI, 1.73-2.40).21 The third study did not present the adjusted rates for this variable; 

unadjusted rates appear in Table 9.46 

Three studies assessed the relationship between personal history of other (non-CRC) cancers 

and CRC screening. Two studies found this variable to be strongly associated with CRC 

screening (AOR, 1.08; 95% CI, 0.93-1.25;151 AOR, 1.24; 95% CI, 1.12-1.37;21 adjusted 

percentage of 59.8 percent screening rate for those with a personal history versus 48.3 percent 

for those without; P < 0.000146). 

Two studies reported use of mammograms and Pap tests.21,46 In one study, analyses for use of 

mammograms were adjusted for all variables in their analysis except sex and Pap test use, and 

those for use of Pap tests were adjusted for all variables except sex and mammogram use and 

also for hysterectomy history.21 For the association between mammography use and CRC 

screening, the AOR was 2.96 (95% CI, 2.50-3.50); for Pap tests the AOR was 2.41 (95% CI, 

2.03-2.86). The second study did not provide adjusted rates for these variables.46 Their 

unadjusted rates indicate that 60.6 percent of females who had obtained a mammogram in the 

47 
past 2 years versus 24.0 percent of females who had not and 56.0 percent of those who had 

obtained a Pap test in the past 3 years versus 33.3 percent of those who had not reported 

obtaining CRC screening within recommended time intervals.46 

Findings specific to the association of general health status with CRC screening differed 

across studies. One study found little difference in CRC screening rates between respondents 

who considered themselves to be in excellent or good health and those in fair or poor health 

(AOR, 1.07; 95% CI, 0.94-1.22).21 The other two studies reported that higher levels of perceived 

health seemed to be associated with higher CRC screening rates (AOR, range 0.73-0.90 with 

“excellent” as the referent group for one study151 and 48.7 percent adjusted rates for those in 

“excellent/very good/good” health and 54.3 percent in “fair” or “poor” health; P < 0.000146). 

Risk factors. Risk factors reported by these studies included smoking status, obesity, physical 

activity, and alcohol use.21,46,151 In two studies, current smokers were less likely than never or 

former smokers to be screened (AOR, 0.82; 95% CI, 0.70-0.9521 and adjusted percentage of 41.5 

percent screening rate for smokers compared with a 53.3 percent rate for former smokers and a 

45.2 percent rate for those who never smoked; P < 0.000146). One study reported no significant 

differences based on current or former smoking.151 

None of the studies reported body mass index as a predictor of CRC screening. All three 

found that even some or moderate, as well as regular, respondents who reported some type of 

exercise had higher screening rates than those who reported no exercise.21,46,151 

Alcohol use was reported in two studies.21,46 One found that those who reported 1 to 14 

drinks per week were more likely to report being screened than any other group (AOR, 1.14; 

95% CI, 1.03-1.26).21 The other study also reported significant differences specific to alcohol 

use; those who reported 1 or more drinks per week being more likely to be screened (adjusted 

percentages of 52.8 percent for those drinking 1 to 13 drinks/week (95% CI, 51.5-54.4%) and 

51.9 percent (95% CI, 47.3-56.4%) for those drinking 14 or more drinks/week; compared with 

46.5 percent (95% CI, 44.8-48.3%) for those reporting no alcohol use: P < 0.0001).46 

Psychosocial factors. Two studies presented analyses based on reasons for never undergoing 

screening or undergoing screening beyond the recommended time intervals and include aspects 

of knowledge, attitudes, beliefs, or perceptions (i.e., psychosocial factors) that may be associated 

with CRC screening use.21,46 One study using 2000 NHIS data examined reasons for not 

obtaining screening compared two age groups of respondents (those 50-64 years compared with 

those ≥ 65 years) and reported that lack of knowledge of either the FOBT or endoscopy as a test 

was a common barrier to undergoing either test (52.0 percent of those 50-64 years of age and 

50.7 percent of those 65 or older reported this barrier for FOBT; 49.7 percent and 50.7 percent, 

respectively, reported this barrier for endoscopy).21 Far fewer respondents reported any of the 

following reasons for not being screened, putting it off, or believing they did not need the test: 

expense or lack of insurance, the pain, unpleasantness, or embarrassment of having the test. 

Proportions ranged from 0.3 percent to 12.2 percent among those 50-64 and from 0.1 percent to 

12.5 percent among those 65 or older.21 

The study using 2005 NHIS data presented proportions of responses for the same items of the 

survey;46 they compared individuals who never had had an FOBT or endoscopy with those who 

had had the test before but not in the recommended time interval. Results indicated that about 

half of the respondents reported “never thought about it” as a reason for not being screened ever 

(adjusted percentage of 53.9 percent (95% CI, 52.0-55.7%) for FOBT and 51.8 percent (95% CI, 

49.9-53.6%) for endoscopy) or within the time interval (adjusted percentage of 51.7 percent 

(95% CI, 50.0-53.4%) for FOBT and 48.7 percent (95% CI, 47.0-50.4%) for endoscopy).46 Far 

fewer respondents reported any of the psychosocial factors as reasons for not being screened ever 

or on time, such as their beliefs about testing (“did not need it”, adjusted percentage ranges of 

48 
10.3 to 12.2 percent), or their perceptions that the tests were too painful/unpleasant/embarrassing 

(adjusted percent ranges of 0.8 to 2.0 percent).46 Neither study commented on the extent to which 

any of these factors may relate to overall screening rates. 

Patient Factors: Overview of Additional Studies 

Here we present information from other studies that present findings from a national, 

regional, or local database, but that stratified their findings on one or more particular patientlevel factor (e.g., age, sex, race, ethnicity). We highlight these studies in the sections specific to 

the variable of interest. To reduce the potential for redundancies, we only present the study 

characteristics and overview of results for each group of studies, and not a detailed description of 

all the studies included in this section. 

In addition to the three overview studies, we included 53 studies1-2,42,55-56,65,106-109,111-126,128­

134,136-138,141,144-147,149-150,155-158,160-163,165-166 rated as good or fair quality. We present findings in 

summary tables for studies that had significant or particularly important or interesting results 

specific to that patient-level variable. Each table first presents studies rated as good quality listed 

in alphabetical order by first author’s last name, followed by studies rated as fair quality that are 

also listed in alphabetical order by the first author’s last name. Also, because we are reporting 

findings for a large number of studies, we have attempted to streamline the text such that detailed 

statistics (e.g., confidence intervals [CI]) are only presented in the summary tables and overall 

findings are presented in the text describing the studies. We also describe, just in text, other 

studies that provide supporting or contradicting results for each category of factors. 

Although a large number of studies may have included the factors as presented in the 

following sections, we only present additional description in the text and include in the tables 

those studies that specifically aimed to explain whether the factor of interest for the section was 

related to CRC screening (rather than simply looked at a large number of factors). In some cases 

(for studies specific to both racial and ethnic differences), we include one study in more than one 

summary table. However, to minimize the discussion as much as possible, we generally present 

one study only once in a table and a few studies are not presented in summary tables at all 

because their findings support others presented. At the summary of each factor, we then briefly 

reference all of the other studies that included the factor in their final multivariate analyses and 

whether and how they found the factor to be associated with CRC screening. 

Age. Study characteristics. All studies discussed in this section included age in their analysis 

of factors associated with CRC screening of their sample. Two studies, both rated fair quality, 

focused on the association between age and CRC screening (Table 10); both presenting results 

for patients 65 years or older.55,150 One study presented self-reported findings from a national 

database of responses to the 2003 Health Information National Trends Survey (HINTS);55 we 

include it here (instead of as an overview study) because the authors explored screening 

specifically among older people (ages 65-89 years). The second study analyzed 2002-2003 

Medicare physician/supplier billings claims data from three states (Florida, Illinois, and New 

York).150 The HINTS study focused on the outcome of screening as defined by national 

guidelines (i.e., FOBT in the past year or FS/colonoscopy in the past 10 years), whereas the 

Medicare claims study defined CRC screening as any test (i.e., colonoscopy, FS, double-contrast 

barium enema, or FOBT) obtained during the study period (2002-2003).150 In terms of the “age” 

variable, one study focused on comparing those who were ages 65-74 years with those who were 

75-89 years of age55 the other categorized the age variable into four groups (ages 65-69; 70-74; 

75-79; and 80 or more years).150 

49 
200855 

Table 10. Studies of the association of age with CRC screening 

Author, Year 

Study Design 

Population Variables 

Setting Primary Outcome Potential Associated 

Sample Size of Interest for Predictors Confounders/ with CRC 

Quality Study Aims Review Examined Considered Screening* Results (95% CI) 

Berkowitz et al., 

Cross-sectional, 

retrospective, 

national 

HINTS (2003) 

respondents 65­

89 years old 

N = 1,148 (583 

not up-to-date 

with screening) 

Fair 

Assess beliefs 

and 

perceptions of 

risk about 

CRC and 

gaps in 

knowledge 

about 

screening in 

adults aged 

65-89 years 

FOBT (within past Age (65-74 

year) or FS or vs. 75-89 

colonoscopy in years) 

past 10 years 

(self-report) 

Gender, race, 

income, 

education, 

marital status, 

family history of 

CRC, health 

status, regular 

source of care, 

annual MD 

visits, 

knowledge 

about CRC and 

testing, beliefs 

about CRC, 

perceived risk 

↑ Older patients 

(75-89 years) 

Older patients were 

more likely than 

younger patients to be 

up to date with CRC 

screening (AOR, 1.92; 

95% CI, 1.32-2.79; 

P < 0.001) 

Ananthakrishnan 

et al., 2007150 

Cross-sectional, 

retrospective, 3 

states 

Medicare 

physician/ 

supplier billing 

claims in Florida, 

Illinois, and New 

York, 2002-2003, 

65+ years 

N = 596,470 

Fair 

Identify effects 

of some 

demographic 

characteristics 

on screening 

behavior 

Any test Age (65-69; Race, sex, per- ↓ Oldest Patients 80+ years 

(colonoscopy, FS, 70-74; 75-79; capita income, patients were less likely to 

double-contrast 80+) education have received any 

barium enema, or CRC test than other 

FOBT) (claims) age groups, regardless 

of income (RR range, 

0.84-0.90). 

AOR, adjusted odds ratio; CI, confidence interval; CRC, colorectal cancer; FOBT, fecal occult blood test; FS, flexible 

sigmoidoscopy; HINTS, Health Information National Trends Survey; MD, Medical Doctor; P, probability; RR, relative risk. 

* Arrow symbols (↓or ↑) are provided as a quick reference point of overall findings and represent the association reported 

between each variable and CRC screening. 

Overview of results. Age was a predictor of screening in the HINTS study such that older 

patients (ages 75-89) were more likely than younger patients (65-74) to be up-to-date with CRC 

screening (AOR, 1.92; P < 0.001).55 Age was also associated with CRC screening in the 

Medicare claims study, until the age of 80 year or older; these older patients were less likely to 

have received any CRC test than any other age groups, regardless of income (RR range, 0.84­

0.90).150 

These findings agree somewhat with the overview studies presented previously.21,46,151 The 

Medicare claims study supports those findings in that screening rates decline slightly among 

patients over age 80 years.150 The HINTS study found an overall increase in screening rates from 

the younger age range of respondents (65-74) to the older age group (75-89).55 If these 

investigators had defined more but shorter age ranges in their analysis, they might have found 

rates with respect to age similar to those in the other four studies.21,46,150-151 

50 
Of all the studies that included age as a variable in their adjusted logistic regression models, 

20 reported that older patients (i.e., ages 60-75) were more likely than younger patients (i.e., 50­

60 years) to be current with CRC screening and that rates among the very old age groups (i.e., 76 

years or older) were lower than those for younger age groups.1-2,42,56,107-108,111,114,116,120,122,126,132­

133,138,146,156-158,163 Four studies reported no differences in screening for age groups included in 

their analyses.106,109,130,166 

Sex. Study characteristics. As with the age variable, all studies included this patient variable 

in their analyses of factors associated with CRC screening. Two, both rated as good quality, 

focused specifically on this demographic factor (Table 11).42,133 Both presented national-level 

findings of self-reported data with all results stratified by gender; one presented findings from 

the 2002-2003 HINTS133 and the second presented findings from the 2000 NHIS.42 Both studies 

presented findings for respondents 50 year of age or older.42,133 Both also used the same 

indicators to assess the outcome of screening (i.e., FOBT in the past year or endoscopy in the 

past 10 years).42,133 

Table 11. Studies of the association of sex with CRC screening 

Author, Year 

Study Design 

Population 

Setting 

Sample Size 

Quality Study Aims 

Primary Outcome 

of Interest for 

Review 

Predictors 

Examined 

Potential 

Confounders/ 

Considered 

Variables 

Associated 

with CRC 

Screening* Results (95% CI) 

McQueen et al., 

2006133 Examine 

correlates of 

Any test 

(endoscopy in the 

Gender Age, gender, 

race, 

↑ of FOBT 

among female 

Females reported 

slightly higher 

test use by last 10 years or education, lifetime (ever) and 

Cross-sectional, gender FOBT in the last number of No differences recent use of FOBT 

national year) (self-report) physician visits by gender for than males (17.1% 

in past year, other tests lifetime and 9.3% 

HINTS, 2002­ family history of recent for female; 

2003, 50+ years CRC and 12.1% lifetime 

and 5.2% recent for 

N = 2,686 male) 

Good 

Peterson et al., 

200742 Explore 

gender 

Any test (FS or 

colonoscopy in the 

Gender Age, gender, 

ethnicity/ 

No gender 

differences in 

Females were not 

less likely than 

differences in last 10 years or race, current CRC males to be current 

Cross-sectional, use of CRC FOBT in the last education, screening in testing for CRC 

national screening year) annual income, rates (AOR 0.98; 95% CI, 

tests and insurance 0.88-1.08) 

NHIS, 2000, 50+ gender- type 

years specific 

correlates of 

N = 11,487 CRC testing 

Good 

AOR, adjusted odds ratio; CI, confidence interval; CRC, colorectal cancer; FOBT, fecal occult blood test; FS, flexible sigmoidoscopy; HINTS,
 

Health Information National Trends Survey; NHIS, National Health Interview Survey. 

*Arrow symbols (↓or ↑) are provided as a quick reference point of overall findings and represent the association reported between each variable 

and CRC screening. 

Overview of results. Much like the three national studies,21,46,151 gender was not consistently 

associated with CRC screening. One study showed that females and males were similar in their 

current screening rates for any test (37.0 percent and 37.1 percent, respectively),42 and the other 

presented findings showing the same patterns of use (66.4 percent for females and 61.8 percent 

for males).133 However, these studies did find differences among males and females for specific 

tests.42,133 In one study, females were more likely than males to report having completed an 

51 
FOBT in the past year (9.3 percent compared to 5.2 percent, respectively); the groups did not 

differ in endoscopy screening in the past 10 years.133 The other study found no gender 

differences in current CRC screening rates.42 

Of the studies in the patient characteristics section of this review that included this variable in 

their adjusted logistic regression models, 14 reported an association between gender and CRC 

screening. Males had higher rates of screening for all tests than females in seven 

studies;1,113,126,137,158,163,166 females had higher rates overall than males in three studies;56,157,169 

females were more likely than males to report a recent FOBT than males in two studies;2,133,138 

and males were more likely than females to have had an endoscopy (either colonoscopy or FS) in 

two studies.2,114,138 An additional 12 studies with sex as a variable in their final analyses found no 

differences in CRC screening.42,55,106-109,111,116,122,132,134,160 

Race. Study characteristics. We consider six studies here because they focused specifically 

on the association between race and CRC screening (Table 12); we rated two as good quality1,158 

and four as fair quality.114,122,129,150,165 In terms of race, we present only those findings specific to 

Blacks1,114,129,150,158,165 or American Indians and Alaska Natives.122 Studies specific to Asians 

appear below in ethnicity because we cite findings specific to subgroups of Asians. 

Of the six studies considered here, four provided findings for non-Hispanic whites compared 

with non-Hispanic blacks;1,114,129,158 one presented findings for whites and all nonwhites;165 and 

one compared American Indians living in the Southwest United States with Alaska Natives.122 

Two presented findings from a national sample of respondents;1,129 two presented findings from 

several states;122,150,165 and two presented locally based findings.114,158 Three studies reported 

self-reported findings from survey data;114,122,129 two others presented findings from medical (or 

Medicare) claims data;150,158,165 and the sixth presented findings from a combination of 2001­

2005 Medical Expenditure Panel Survey (MEPS) and the 2000-2004 NHIS.1 Those included in 

the samples were 50 years of age or older,1,114,122 50-75 years of age,158 65 years of age or 

older,129,150 or 70-79 years.165 

In terms of the screening outcome, there were several different variations of how this was 

operationalized: 

•	 Three studies defined up-to-date screening as those who reported FOBT in the past 

year, FS in the past 5 years, or colonoscopy (double-contrast barium enema for one of 

these) in the past 10 years.114,129,158 

•	 One study defined screening as FOBT in the past 2 years or endoscopy at any time;1 

•	 One study defined CRC screening as FOBT in the past year, and FS or colonoscopy 

in the past 5 years, 165; and 

•	 Another study only included colonoscopy or FS in the past 5 years (excluding 

FOBT).122 

Overview of results. All but two of these studies122,165 gave both unadjusted (AOR ageadjusted only) rates for CRC test usage by various racial groups and rates from multivariable 

analysis that included factors that are known or thought to be associated with CRC screening. 

The four studies that compared CRC screening for non-Hispanic whites and either non-Hispanic 

blacks/Blacks1,114,129,158 reported inconsistent findings. The two studies based on nationally 

52 
Table 12. Studies examining the association between race and CRC screening 

Author, Year 

Study Design 

Population Primary Potential Variables 

Setting Outcome of Confounders/ Associated 

Sample Size Interest for Predictors Modifiers with CRC 

Quality Study Aims Review Examined Reported Screening Results (95% CI) 

Jerant et al., Examine FOBT in past 2 Race (non- Age, gender, No differences Absolute rates for 

20081 correlates of years; Hispanic metropolitan based on race screening among 

screening endoscopy at whites and statistical area, blacks were 25.5% for 

Cross-sectional, among all 4 any time blacks) region, year FOBT; 38.3% for 

retrospective, major US (combined data) endoscopy; and 48.2% 

national racial/ethnic for the combined tests; 

categories among non-Hispanic 

MEPS, 2001- (non-Hispanic whites, rates were 

2005, combined white, Asian, 25.8%, 49.0, and 

with NHIS, 2000- black, and 57.2%, respectively. 

2004, ≥ 50 years Hispanic 

individuals) Initial analysis 

N = 22,973 (adjusted for 

demographics) 

Good showed blacks to be 

significantly less likely 

than non-Hispanic 

whites to have CRC 

tests (unadjusted OR 

0.72; 95% CI, 0.65­

0.80). 

Further adjustment to 

the model (i.e., when 

foreign birth, language 

spoken at home are 

taken into account) 

eliminated these 

differences. 

Christman, et al. 

2004158 

Cross-sectional, 

retrospective, 

local 

Community health 

center, 2002, 

Florida, 50-75 

years 

N = 1,176 

Good 

Determine the 

rate of CRC 

screening in 

patients 

attending a 

sample of 

community 

health centers 

Any test (FOBT 

in past year, FS 

in past 5 years, 

colonoscopy or 

double-contrast 

barium enema 

in the previous 

10 years) 

(claims) 

Race 

(Black, 

white, 

Hispanic) 

Age, gender, 

marital status, 

insurance 

status, access 

to care 

Charlson 

Comorbidity 

Index, health 

status, 

screening 

behavior 

↑ Blacks Unadjusted rates for 

CRC screening: 

40.1% whites; 51.3% 

Blacks 

Blacks were more 

likely to have been 

screened for CRC 

than whites (AOR, 

1.38; 95% CI, 1.04­

1.84; P = 0.03) 

53 
Table 12. Studies examining the association between race and CRC screening (continued) 

Author, Year 

Study Design 

Population Primary Potential Variables 

Setting Outcome of Confounders/ Associated 

Sample Size Interest for Predictors Modifiers with CRC 

Quality Study Aims Review Examined Reported Screening Results (95% CI) 

Fenton et al., 

2009165 Assess 

changes in 

FOBT in past 

year or 

Race 

(whites, 

Age, sex, 

rural/urban, 

↓ Blacks for 

colonoscopy 

Up-to-date screening 

in whites ranged from 

screening FS/colonoscopy blacks) income, 39.4% to 47.3%, while 

Cross-sectional, rates among in past 5 years comorbidity, No differences those in blacks ranged 

retrospective, which geographic based on race from 29.0% to 38.1%. 

regional compared to region for FOBT or FS (CI provided in graphic 

nonwhite form in manuscript; all 

Medicare claims Medicare statistically significant) 

data in 9 states, enrollees 

mid-1995 through 

2003, 70-79 years 

N = 60,450 

Fair 

O’Malley, et al., 

2005129 Quantify the 

size of any 

FOBT in past 

year, FS in past 

Race 

(white, 

Age, sex; SES 

(education, 

No differences 

based on race 

Unadjusted rates: 

Whites - 48.2% (95% 

racial 5 years, black) income) CI, 46.4-50.0%) 

Cross-sectional, differences in colonoscopy in Blacks - 39.1% (95% 

retrospective, the receipt of past 10 years CI, 35.7-42.6%) 

national CRC (self-report from 

screening MCBS) Racial differences 

MCBS linked to among were eliminated after 

Medicare claims beneficiaries adjustment for SES 

and ARF, 2000, (i.e., education, 

Medicare income) 

beneficiaries, 

65 years or older 

N = 9985 

Fair 

Schumacher, et 

al. 2008122 

Cohort study, 

several states 

(Alaska, 

Southwest United 

States) 

Baseline survey, 

2004-2007, 

American 

Indian/Alaska 

Natives, 50+ 

years 

N = 2,779 

Fair 

Investigate 

predictive 

factors 

associated 

with receiving 

each of the 

cancer 

screening 

tests 

Colonoscopy or 

FS in past 5 

years (selfreport) 

Race 

(American 

Indian and 

Alaska 

Native) 

Age, location, 

gender, 

education, 

family history of 

cancer, family 

history of CRC, 

smoke 

cigarettes in 

past 5 years, 

history of 

chronic medical 

condition, 

language, 

residency, 

income, other 

screening tests 

↓ Southwest 

American Indian 

compared to 

Alaska Natives 

Overall screening rate 

was 22% 

Alaska Natives were 

more likely to have 

obtained CRC 

screening than 

Southwest American 

Indians (AOR, 3.86; 

95% CI, 2.92-5.10) 

54 
Table 12. Studies examining the association between race and CRC screening (continued) 

Author, Year 

Study Design Primary 

Population Outcome of Potential Variables 

Setting Interest for Confounders/ Associated 

Sample Size Review Predictors Modifiers with CRC 

Quality Study Aims Examined Reported Screening Results (95% CI) 

Thorpe, et al., 

2005114 Examine 

characteristics 

Any test per 

guidelines 

NonHispanic Age, race, 

family and 

↓ non-Hispanic 

blacks for 

Respondents who 

were non-Hispanic 

of people (FOBT within whites and neighborhood colonoscopy in blacks were less likely 

Cross-sectional/ undergoing past year, FS in Non- income, past 10 years; than non-Hispanic 

retrospective, screening past 5 years, or Hispanic ethnicity, no differences whites (unadjusted 

local within colonoscopy in blacks gender, for other timely rates) to be up-to-date 

guidelines past 10 years) personal risk tests with CRC screening 

Community or colonoscopy factors (i.e., (52.3%; 95% CI, 48.2­

Health Survey, within past 10 current 56.4 compared with 

2003, New York years smoking, 60.3; 95% CI, 57.8­

City residents (self-report) physical 62.8, respectively) 

≥ 50 years inactivity), 

access to care, Adjusted rates showed 

N = 3,606 insurance, no differences 

regular source between non-Hispanic 

Fair of care whites and nonHispanic blacks in 

screening by any 

timely screening test 

(AOR, 0.92; 95% CI, 

0.74-1.13) but did 

show that nonHispanic blacks were 

less likely to have 

received a 

colonoscopy in the 

past 10 years when 

compared with nonHispanic whites (AOR, 

0.72; 95% CI, 0.58­

0.91) 

AOR, adjusted odds ratio; CI, confidence interval; CRC, colorectal cancer; FOBT, fecal occult blood test; FS, flexible sigmoidoscopy; MEPS, 

Medical Expenditure Panel Survey; NHIS, National Health Interview Survey; P, probability; MCBS, Medicare Current Beneficiary Survey; ARF, 

Area Resource File; SES, socioeconomic status. 

* Unadjusted rates by race were not provided. 

† Arrow symbols (↓or ↑) are provided as a quick reference point of overall findings and represent the association reported between each variable 

and CRC screening. 

representative samples found no difference in adjusted screening rates and race;1,129 one study 

reported that non-Hispanic blacks were less likely to be screened than non-Hispanic whites114 

and one study reported that Blacks were statistically significantly more likely to be screened for 

CRC than whites (P = 0.03).158 The study of Medicare claims data in 9 states among 70-79 year 

olds compared changes in screening over time for whites and blacks. In 1995, 39.4 percent of 

White enrollees were up-to-date with CRC screening compared with 29 percent of Blacks. In 

2003, overall percentages of enrollees up-to-date increased, but disparities between racial groups 

persisted, with 47.3 percent of Whites up-to-date compared with 38.1 percent of Blacks. The 

differences were statistically significant between all groups in both 1995 and in 2003.165 

Additional studies not highlighted here used race as a variable in their final multivariate 

analysis. One reported that non-Hispanic blacks were more likely than non-Hispanic whites to 

report being screened;107 six noted that non-Hispanic whites were more likely than non-Hispanic 

blacks (or non-whites) to report being current with screening106,120,128,138,142 or ever screened;125 

and nine reported no differences by race.42,55,111,119,132,134,147,156-157 Finally, the study giving 

55 
findings specific to Southwest American Indians and Alaska Natives found that Alaska Natives 

were more likely than those in the Southwest United States to report being screened (AOR, 

3.86).122 

Ethnicity - Hispanics. Study characteristics. Six studies (7 articles) had the specific aim of 

examining the relationship between Hispanic ethnicity and CRC screening (Table 13), Of these, 

we rated two as good quality;1,141,147 they used self-reported findings from a nationally 

representative sample collected either through the NHIS in 1998147 or a combination of the 2000­

2004 NHIS and 2001-2005 MEPS.1,141 The four studies we rated as fair quality included one of 

2000 NHIS findings,111 another of changes from 2000 NHIS compared to 2003 data,119 one of a 

trend analysis of 2000 NHIS data compared with 2005 data,113 and one of respondents living in a 

local county in 1998-1999 that was reported in two separate articles.116-117 

Table 13. Studies of the association of Hispanic origin with CRC screening 

Author, Year 

Study 

Design 

Population 

Setting 

Sample Size 

Quality Study Aims 

Primary 

Outcome of 

Interest for 

Review 

Predictors 

Examined 

Potential 

Confounders/ 

Modifiers 

Reported 

Variables 

Associated 

with CRC 

Screening* Results (95% CI)† 

Goel et al., 

2003147 Determine 

whether 

FOBT in past 

year or 

Hispanic vs. 

nonAge, marital status, 

↓ Hispanics Unadjusted screening rates: 

non-Hispanic whites: 28% 

Crossforeign birthplace‡ proctoscopy 

(as a proxy for 

Hispanic 

white 

geographic 

region, 

FOBT, 30% FS; Hispanics: 

18% FOBT, 20% FS; 

sectional, explains FS) in past 5 education, P<0.005 

retrospective, some years income, health 

national racial/ethnic (self-report) status, Hispanics were less likely 

disparities in comorbidities, than non-Hispanic whites to 

NHIS, 1998, cancer body mass have been screened for 

≥ 50 years screening index, 

hospitalizations 

FOBT (AOR, 0.75; 95% CI, 

0.59-0.94) or FS (AOR, 0.77; 

N = 32,440 in prior year, 95% CI, 0.62-0.96) 

(15% foreignborn) 

access to care 

(i.e., insurance 

status, visits in 

Adjusted for above plus 

language spoken at home, 

Good past year, usual nativity: 

source of care) AOR, 1.0; 95% CI, 0.85-1.18 

Jerant et al., 

2008141 Identify 

independent 

FOBT in past 

2 years or 

Ethnicity 

(Mexican, 

Age, gender, 

region, year, 

↓ Mexican or 

Dominican 

Total unadjusted screening 

rates: 

contributions endoscopy Cuban, income, Non-Hispanic whites: 55.9% 

Cross- of basic ever Puerto education, After Mexican: 35.2% 

sectional, demo­ (self-report) Rican, insurance, usual adjustments Cuban: 51.0% 

retrospective, graphics, Dominican) source of care, made for Puerto Rican: 45.7% 

national socio­ vs. non- race, ethnicity language Dominican: 28.5% 

economic Hispanic ethnicity/race, spoken at 

MEPS, 2001­ factors, white country of origin home, there Adjusted for age, gender, 

2005, access were no region, and year: 

combined barriers, and differences in Mexican: (AOR, 0.46; 95% 

with NHIS, language- screening CI, 0.40-0.53) 

2000-2004, based rates. Puerto Rican: (AOR, 0.65; 

≥ 50 years barriers to 95% CI, 0.47-0.91) 

56 
2008141 

Table 13. Studies of the association of Hispanic origin with CRC screening (continued) 

Author, Year 

Study 

Design 

Population 

Setting 

Sample Size 

Quality Study Aims 

Primary 

Outcome of 

Interest for 

Review 

Predictors 

Examined 

Potential 

Confounders/ 

Modifiers 

Reported 

Variables 

Associated 

with CRC 

Screening* Results (95% CI)† 

Jerant et al., 

(continued) 

N = 22,419 

Good 

Shih et al., 

2006119 

Crosssectional, 

retrospective, 

national 

NHIS, 2000 

and 2003 

CCS, 

Medicare 

beneficiaries, 

65 years or 

older 

N = 6,180 (in 

2000); 5,759 

(in 2003) 

Fair 

disparities in Dominican: (AOR, 0.30; 95% 

CRC CI, 0.19-0.45) 

screening Adjusted for above plus 

income and education: 

Mexican: (AOR, 0.70; 95% 

CI, 0.60-0.81) 

Dominican: (AOR, 0.44; 95% 

CI, 0.28-0.69) 

Adjusted for above plus 

insurance, usual source of 

care, health status: 

Mexican: (AOR, 0.79; 95% 

CI, 0.69-0.91) 

Dominican: (AOR, 0.54; 95% 

CI, 0.32-0.91) 

Explore Ever received Race/ SES variables ↓ Hispanics Unadjusted screening rates 

whether endoscopy ethnicity and access were approximately 30% 

changes in (non­ barriers among Hispanics in 2000, 

Medicare Hispanic with only a slight increase by 

reimburseme whites, 2003. Screening among nonnt for Hispanics) Hispanic whites was 

colonoscopy approximately 45% in 2000, 

addressed increasing to 50% in 2003 

ethnic (findings presented only in a 

disparities bar chart). 

Odds of screening declined 

for Hispanics between 2000 

and 2003 and the differences 

between Hispanics and nonHispanic whites became 

significant in 2003 (AOR; 

0.77; 95% CI, 0.59-0.99; 

P = 0.048). 

Thompson et 

al., 2005116 

Thompson et 

al., 2006117 

Crosssectional, 

retrospective, 

local 

Survey in 20 

communities 

Lower 

Yakima 

Valley, 

Compare 

CRC 

screening 

prevalence 

and the 

association 

between 

reported 

barriers and 

screening 

participation 

between 

Hispanics 

and nonHispanic 

whites 

FOBT in past Hispanics Age, gender, 

2 years or vs. non- income, access 

endoscopy in Hispanic to health 

past 5 years whites insurance, 

(self-report) smoking, 

residential 

community 

↓ Hispanic for 

endoscopy in 

past 5 years 

No differences 

for other tests 

Unadjusted screening rates: 

FOBT ever: non-Hispanic 

whites 55.7%; Hispanics 

40.6%; P = 0.003 

No difference for FOBT in 

past 2 years 

Endoscopy ever: nonHispanic whites 44.4%; 

Hispanics 26.9%; P <0.001 

Endoscopy in past 5 years: 

non-Hispanic whites 33.7%; 

Hispanics 24.1%; P <0.05 

Adjusted rates were only 

significant for endoscopy in 

57 
Table 13. Studies of the association of Hispanic origin with CRC screening (continued) 

Author, Year 

Study 

Design 

Population Primary Potential Variables 

Setting Outcome of Confounders/ Associated 

Sample Size Interest for Predictors Modifiers with CRC 

Quality Study Aims Review Examined Reported Screening* Results (95% CI)† 

Thompson et 

al., 2005116 

Thompson et 

al., 2006117 

(continued) 

Washington, 

1998-1999, 

≥ 50 years 

n = 1,795 

Fair 

Trivers, et al., 

2008113 

Crosssectional, 

retrospective, 

national 

NHIS, 2000 

compared 

with 2005, 

50-64 years 

N = 6,020 in 

2000; 6,706 

in 2005 

Fair 

Determine 

whether 

progress was 

made 

between 

2000 and 

2005 in 

reducing 

CRC 

screening 

disparities by 

race, 

ethnicity, 

income, and 

insurance 

status 

Any test 

(FOBT within 

past year, FS 

or 

colonoscopy 

in past 10 

years) (selfreport) 

Hispanic 

and nonHispanic 

Age, gender, 

race, ethnicity, 

poverty ratio, 

insurance, 

education, 

region, years in 

United States 

↓ Hispanic 

females vs. 

non-Hispanic 

female 

past 5 years (AOR, 0.52; 

95% CI, 0.28–0.98) 

Unadjusted screening rates: 

In 2000 among male: 

23.6% Hispanics compared 

with 39.3% for non-Hispanic 

whites 

Among female: 28.9% 

Hispanics compared with 

37.7% non-Hispanic whites 

In 2005 among male: 31.3% 

Hispanics compared with 

45.1% non-Hispanic whites 

Among female: 27.1% 

Hispanics compared with 

46.3% non-Hispanic whites 

Wee, et al., 

2004111 

Crosssectional, 

retrospective, 

national 

NHIS, 2000, 

50-75 years 

N = 11,427 

Fair 

Examine 

whether 

disparities in 

CRC 

screening 

persist in 

year 2000. 

FOBT in past 

year; FS in 

past 5 years; 

or 

colonoscopy 

in past 10 

years 

(self-report) 

Race/ 

ethnicity 

(white, 

black, 

Hispanic, 

other) 

Age, race or 

ethnicity, 

educational 

level, region of 

the country, 

body weight as 

classified into 

standard body 

mass index 

categories, 

family history of 

CRC, healthcare 

access, smoking 

status, illness 

burden 

↓Hispanic Unadjusted screening rates: 

Whites FOBT 25%, 

endoscopy 31%; 

Hispanics FOBT 15%, 

endoscopy 19%; P <0.001 

No difference in screening by 

endoscopy 

Adjusted rates with nonHispanic whites as referent: 

FOBT: (AOR, 0.7; 95% CI, 

0.5-0.9) 

endoscopy: (AOR, 0.8; 95% 

CI, 0.6-1.0) 

either: (AOR, 0.7; 95% CI, 

0.6-0.9; all P < 0.05) 

AOR, adjusted odds ratio; BRFSS, Behavioral Risk Factor Surveillance System; CCS, Cancer Control Supplement; CI, confidence intervals; 

CRC, colorectal cancer; FOBT, fecal occult blood test; FS, flexible sigmoidoscopy; MEPS, Medical Expenditure Panel Survey; NHIS, National 

Health Interview Survey; P, probability. 

* Arrow symbols (↓or ↑) are provided as a quick reference point of overall findings and represent the association reported between each variable 

and CRC screening.

†

 Only adjusted rates that are statistically significant are presented. 

‡

 Results for acculturation, language, and foreign birth are presented separately below (see acculturation, language, foreign birth). 

58 
Studies in this section used either non-Hispanic whites or non-Hispanics (any race) as the 

comparison group. Three studies used all respondents 50 years of age or older in their 

sample;1,116,141,147 one focused on those 50-64 years,113 another included those 50-75 years,111 

while one study focused on Medicare beneficiaries aged 65 or older.119 

The definition of the outcomes of being up-to-date with screening varied across the studies 

and included the following: 

•	 One study defined CRC screening as FOBT in the past year or endoscopy in the past 10 

years;113 

•	 One study (of the same sample) defined being screened as FOBT in the past 2 years or 

endoscopy in the past 5 years;116-117 

•	 One study defined being screened as FOBT in the past year, FS in the past 5 years, or 

colonoscopy in past 10 years;111 

•	 One study defined being screened as FOBT in the past year and proctoscopy in the past 5 

years;147 

•	 One study was focused on only screening by endoscopy (ever received);119 

•	 One study defined being screened as having an FOBT in the past 2 years and ever having 

had an endoscopy.1,141 

We present both unadjusted (or age-adjusted only) rates for CRC test usage by persons of 

Hispanic ethnicity compared with rates for some other group, as well as rates adjusted by 

potential confounding variables. 

Overview of results. Comparisons of absolute screening rates consistently show that Hispanic 

ethnicity is associated with lower CRC screening test usage. Overall, adjustment for 

socioeconomic and health care access factors significantly attenuates, but generally does not 

eliminate, this disparity. Studies are mixed regarding the relative effect sizes of socioeconomic 

status and health care access in attenuating these differences. One study that explored the impact 

of changes in Medicare reimbursement on endoscopy use by different racial and ethnic groups 

found that, while there were increases in rates among non-Hispanic whites and blacks between 

2000 and 2003 (per NHIS data), the difference between non-Hispanic whites and Hispanics in 

obtaining this test widened during this time period, to a statistically significant gap 

(P = 0.048).119 One national-level study of both MEPS (2001-2005) and NHIS (2000-2004) data 

included in this section stratified their analysis by Hispanic subgroup and showed that disparities 

for persons of Mexican and Dominican origin were greater than for persons of Cuban or Puerto 

Rican origin.141 Their findings indicate that respondents of Mexican or Dominican origin are less 

likely than non-Hispanic whites to be up-to-date with CRC screening (in a model adjusted for 

demographics and access to care, Mexicans had AOR, 0.70 and Dominicans had AOR, 0.44). 

However, no differences were found across the Hispanic subgroups once language was 

incorporated into the model.141 

Additional studies not examined in detail here presented related findings. Four studies 

demonstrated that the adjusted rates for screening were lower among Hispanics than nonHispanic whites;115,120,126,163 evidence from six other studies suggested that screening rates did 

not differ among Hispanics.42,55,107,112,157-158 

Ethnicity - Asians. Study characteristics. Because several studies provide findings for 

different groups of Asians, we present these findings here (Table 14).1-2,109,118,130 We included 

five studies, all based on self-reported data that examine screening rates among Asians: two had 

data for Asians overall,1-2 and three give data for specific groups of Asians.109,118,130 

59 
Of the two studies of Asians overall, one rated as good quality reported findings from a 

combined national dataset of 2001-2005 MEPS and 2000-2004 NHIS’1

 the other, rated as fair 

Table 14. Studies of the association of Asian American origin with CRC screening 

Author, Year 

Study Design 

Population Potential Variables 

Setting Primary Outcome Confounders/ Associated 

Sample Size of Interest for Predictors Modifiers with CRC 

Quality Study Aims Review Examined Reported Screening Results (95% CI) 

Jerant et al., 

20081 

Crosssectional, 

retrospective, 

national 

MEPS, 2001­

2005, 

combined with 

NHIS, 2000­

2004, ≥ 50 

years 

N = 22,973 

Good 

Examine 

correlates of 

screening 

among all 4 

major US 

racial/ethnic 

categories 

(nonHispanic 

white, Asian, 

black, and 

Hispanic 

individuals) 

FOBT in past 2 

years; endoscopy at 

any time 

Asians vs. 

nonHispanic 

whites 

Age, gender, ↓ Asians 

metropolitan 

statistical area, 

region, year 

Unadjusted screening 

rates: 

Asians: 14.8% FOBT; 

27.5% endoscopy; 

33.8% combined FOBT 

and endoscopy 

Non-Hispanic whites: 

25.8% FOBT; 49.0% 

endoscopy; 57.2% 

combined FOBT and 

endoscopy 

Adjusted for age, 

gender, region: 

AOR, 0.41; 95% CI, 

0.33-0.50 

Adjusted for above plus 

income and education: 

AOR, 0.42; 95% CI, 

0.34-0.52 

Adjusted for above plus 

insurance, usual source 

of care, health status: 

AOR, 0.44; 95% CI, 

0.35-0.55 

Adjusted for above plus 

language spoken at 

home, nativity: 

AOR, 0.63; 95% CI, 

0.49-0.81 

Wong et al., 

20052 

Crosssectional, 

retrospective, 

state 

California 

Health 

Interview 

Survey, 2001, 

≥ 50 years 

Factors 

related to 

screening 

rates among 

Asian 

Americans 

compared 

with nonLatino 

whites 

FOBT in past year or 

endoscopy in past 

10 years, or both 

(self-report) 

Asian 

Americans 

(Koreans, 

Filipinos, 

Chinese, 

South Asian, 

Japanese, 

and 

Vietnamese) 

Ethnic group, 

age, gender, 

education, 

marital status, 

household size 

and income, 

years in US, 

comorbidities, 

English 

language 

proficiency, 

↓ Filipino for 

ever having 

had or being 

current for 

endoscopy 

↓ Korean for 

ever having 

FOBT 

Unadjusted screening 

rates: 

Ever screened: 

Any test: 75% nonHispanic whites 

compared with a low of 

49% for Koreans and a 

high range of 72% for 

Japanese 

Up-to-date screened: 

Any test: 62% nonHispanic whites 

compared with low 

60 
Table 14. Studies of the association of Asian American origin with CRC screening (continued) 

Author, Year 

Study Design 

Population Potential Variables 

Setting Confounders/ Associated 

Sample Size Primary Outcome of Predictors Modifiers with CRC 

Quality Study Aims Interest for Review Examined Reported Screening Results (95% CI) 

Wong et al., 

20052 family history 

of CRC 

↑

Vietnamese 

range of 41% for 

Koreans and a high 

(continued) for ever range of 58% among 

having any Japanese 

N = 1,771 test and for Adjusted rates showed 

Asian being up to Koreans were less likely 

Americans date with to have ever had an 

any test but FOBT (AOR, 0.40; 95% 

Fair FOBT CI, 0.25-0.62; 

P < 0.001); and 

Filipinos were less likely 

to have ever received 

an endoscopy (AOR, 

0.62; 95% CI, 0.44­

0.88) or to be up-todate for that test (AOR, 

0.68; 95% CI, 0.48­

0.97; P < 0.05) 

Vietnamese were more 

likely to have ever had 

or be up-to-date with 

any of the tests 

Studies for Specific Asian Groups 

Nguyen, 

2008130 Identify 

determinants 

FOBT alone, FS 

alone in past 5 years, 

Vietnamese 

Americans 

Demographics 

(age, gender, 

No 

comparison 

Overall, 62% had 

received any CRC test; 

of CRC FOBT + FS in past 5 marital status, group 25% were up-to-date on 

Cross, screening years, or colonoscopy years in US, FOBT, 16% were up-tosectional, among in past 10 years (self­ education, date on FS, and 23% 

retrospective, Vietnamese report) employment, were up-to-date on 

counties in 2 Americans insurance, colonoscopy 

states Englishlanguage 

Vietnamese, proficiency, 

2004, income, 

residents of residence), 

counties in access (health 

California or status, usual 

Texas, 50-74 source of 

years care, MD 

ethnicity), 

N = 867 knowledge of 

or attitudes 

Fair about CRC 

and screening 

61 
Table 14. Studies of the association of Asian American origin with CRC screening (continued) 

Author, Year 

Study Design 

Population 

Setting 

Sample Size 

Quality Study Aims 

Primary Outcome of 

Interest for Review 

Predictors 

Examined 

Potential 

Confounders/ 

Modifiers 

Reported 

Variables 

Associated 

with CRC 

Screening Results (95% CI) 

Sun et al., 

2004118 Investigate 

factors 

FOBT only in past 

year, FOBT + FS in 

Chinese 

Americans 

Age, gender, 

marital status, 

No 

comparison 

Overall, 27.9% reported 

FOBT within past year; 

associated past 5 years, or no home owner, group 22.2% reported FS 

Cross- with CRC test citizenship, 

sectional, screening years at 

retrospective, among residence, 

local senior education, 

Chinese income, 

Chinese Americans insurance, 

Americans, employment, 

1999-2000, 3 family history 

senior centers of CRC, 

in New York worries or 

City, ≥ 50 

years 

fears, 

perceived 

susceptibility, 

N = 192 self-efficacy, 

social 

Fair influence, 

intention, 

efficacy of 

screening 

Yip, et al., 

2006109 Identify 

factors 

FOBT in past year, 

FS in past 5 years 

Chinese 

Americans 

Age, gender, 

insurance, 

No 

comparison 

Overall, 39.7% were 

assessed as being 

associated and/or colonoscopy in language group screened for CRC 

Cross- with CRC past 10 years (claims) spoken according to guidelines. 

sectional, screening Of these, 18.9% had 

retrospective, among completed FOBT in 

local Chinese past year, 2.9% 

Americans completed FS in past 5 

Chinese years, and 21.3% 

Americans, completed colonoscopy 

2003-2004, in past 10 years 

community 

health center 

in Seattle, ≥50 

years 

N = 383 

Fair 

AOR, adjusted odds ratio; CI, confidence interval; CRC, colorectal cancer; FOBT, fecal occult blood test; FS, flexible sigmoidoscopy; MEPS, 

Medical Expenditure Panel Survey; N, number; NHIS, National Health Interview Survey. 

* Arrow symbols (↓or ↑) are provided as a quick reference point of overall findings and represent the association reported between each variable 

and CRC screening. 

quality, presented findings from the 2001 California Health Interview Survey (CHIS).2 The three 

studies that present findings for specific subpopulations, all rated as fair quality for this specific 

variable, do not provide screening rates for the population in question compared with rates for 

other groups; they collected primarily convenience samples of patients from either communities 

in two states (California and Texas) with large samples of Vietnamese Americans,130 senior 

centers in New York City with relatively large groups of Chinese Americans,118 and one 

62 
community health center in Seattle with a large Chinese American patient population.109 We 

include these only in this section because of limits in their samples. All but one of the studies 

defined their population as those 50 years or older; one focused on those 50-74 years.130 

The outcome of screening was assessed differently across the studies as follows: 

•	 One study defined being screened as having FOBT in the past year or endoscopy in the 

past 10 years2 

•	 One study defined CRC screening as FOBT in the past 2 years and ever having had an 

endoscopy1 

•	 One study defined being screened as FOBT in the past year, FS in the past 5 years, FOBT 

with FS in the past 5 years, or colonoscopy in the past 10 years130 

•	 One study defined being screened as FOBT in the past year, FOBT with FS in the past 5 

years, or no testing118 

•	 One study defined CRC screening as FOBT in the past year, FS in the past 5 years, or 

colonoscopy in the past 10 years.109 

Overview of results. Comparisons of absolute screening rates consistently show that being of 

Asian descent is associated with lower CRC screening test usage. Overall, adjustment for 

socioeconomic and health care access factors significantly attenuates, but generally does not 

eliminate, this disparity. For the large national study of MEPS and NHIS data, Asians were 

shown to be less likely than non-Hispanic whites to be current with screening, even when all 

adjustments were made for demographics, socioeconomic status, access to care, and language.1 

In the other large study that compared different Asian subgroups on screening rates, the findings 

were mixed, showing that the unadjusted rates of all the Asian groups were consistently lower 

than those for non-Hispanic whites,2 Adjustments to the multivariate analysis eliminated these 

differences for all groups except for endoscopy in Filipinos (AOR, 0.62 for ever use and AOR, 

0.68 for up-to-date use) and ever use of FOBT in Koreans (AOR, 0.40).2

 Vietnamese were 

consistently more likely than non-Hispanic whites to have ever been screened and to be up-todate with all but FOBT (AOR, range 1.24-1.54; P < 0.05); for FOBT, Vietnamese were less 

likely than non-Hispanic whites to have ever received FOBT (AOR, 0.90; P < 0.05), but there 

were no differences for up-to-date screening by FOBT.2 

We also found four studies with some related information that demonstrates the 

inconsistency in findings across studies of Asian use of CRC screening. One reported that Asians 

were less likely than non-Hispanic whites overall to have been screened;114 another reported that 

Asian Americans and Pacific Islanders were less likely than non-Hispanic whites to have 

received an FOBT,147 a third reported no difference in screening rates between Asians and nonHispanic whites,163 and the fourth found that Vietnamese were just as likely as whites to have 

had a FOBT in the past year or colonoscopy in past 10 years but were significantly less likely to 

have received a FS in the past 5 years (P < 0.05).112 

In the three studies that presented findings specific to a subgroup of Asians, one study found 

that 25 percent of Vietnamese were up-to-date with screening;130 another study reported that 27.9 

percent of Chinese American respondents reported FOBT within the past year and 22.2 percent 

reported FS;118 and the third study reported that 39.7 percent of their sample of Chinese 

Americans were current for CRC screening.109 

Acculturation. Study characteristics. We assessed nine studies in terms of the extent to 

which acculturation was a factor in predicting CDC screening (Table 15).1-2,118,120-122,141,147,149,161 

By acculturation, we mean three possible indicators: place of birth (i.e., foreign- or US-born), 

years living in United States, English-language proficiency, or a combination of these. Although 

63 
Table 15. Studies of the association between acculturation and CRC screening 

Author, Year 

Study 

Design 

Population Potential Variables 

Setting Confounders/ Associated 

Sample Size Primary Outcome of Predictors Modifiers with CRC 

Quality Study Aims Interest for Review Examined Reported Screening Results (95% CI) 

Afable- Examine the FOBT in past year; Acculturation Age, sex, ↑ English English language 

Munsuz et al., relationship FS in past 5 years; (i.e., US or income status, language interview was 

2009149 between colonoscopy in past foreign born; education, proficiency positively 

acculturation 10 years and language insurance, for FOBT associated with 

Cross- and CRC (self-report) preference of usual source of FOBT in past year 

sectional, screening interview) care, number ↑ US born (AOR, 2.5; 95% 

retrospective, among older of chronic for CI, 1.1, 5.4) 

national Mexican, diseases endoscopy 

Puerto-Rican, among US born among 

NHIS, 2000, and Cuban Mexicans Mexicans was 

2003, 2005, adults positively 

Latinos 50 ↓ US born associated with 

years or older for FOBT endoscopy (AOR, 

among 1.5; 95% 1.1, 2.2) 

N = 38,347 Puerto and negatively 

(2304 Ricans associated with 

Mexicans; FOBT among 

503 Puerto- Puerto Ricans 

Ricans; 484 (AOR, 0.3; 95% 

Cubans) CI, 0.2, 0.7) 

Good 

Diaz et al., Examine FOBT in past year; English- Age, gender, ↑ English- Latinos responding 

2008161 relationship endoscopy in past 10 language marital status, language in Spanish were 

between years (self-report) proficiency insurance, proficiency 43% less likely to 

Cross- language and (non-Latinos geographic have obtained 

sectional, CRC responding to region CRC screening 

retrospective, screening survey in than non-Latinos 

national among Latinos English; (AOR, 0.57; 95% 

and non- Latinos CI, 0.44-0.74) and 

BRFSS, Latinos responding in 36% less likely to 

2006, ≥ 50 English; have been 

years Latinos screened when 

responding in compared with 

N = 99,895 Spanish) Latinos responding 

in English (AOR, 

Good 0.64; 95% CI, 

0.48-0.84) 

64 
Table 15. Studies of the association between acculturation and CRC screening (continued) 

Author, Year 

Study 

Design 

Population Potential Variables 

Setting Primary Outcome of Confounders/ Associated 

Sample Size Interest for Review Predictors Modifiers with CRC 

Quality Study Aims Examined Reported Screening Results (95% CI) 

Goel, et al., Determine FOBT in past year or Foreign-born Age, marital No Foreign-born 

2003147 whether proctoscopy (as a (born outside status, differences Hispanics and 

foreign proxy for FS) in past US) geographic for foreign- Asian Americans 

Cross- birthplace 5 years region, born and Pacific 

sectional, explains some education, respondents Islanders were just 

retrospective, racial/ethnic income, health once as likely as USnational disparities in status, analysis both Hispanics and 

cancer comorbidities, adjusted for Asian Americans 

NHIS, 1998, screening body mass access to and Pacific 

≥50 years index, care Islanders to have 

hospitalizations been screened by 

N = 32,440 in prior year, FOBT (AOR, 1.05; 

(15% foreign- access to care 95% CI, 0.68-1.64 

born) (insurance for Hispanics; 

status, visits in AOR, 0.62; 95% 

Good past year, CI, 0.29-1.33 for 

usual source of Asian Americans 

care) and Pacific 

Islanders) or for 

proctoscopy (AOR, 

0.89; 95% CI, 

0.59-1.37 for 

Hispanics; AOR, 

0.96; 95% CI, 

0.44-2.09 for Asian 

Americans and 

Pacific Islanders) 

Jerant, et al., Examine FOBT in past 2 years Language Age, sex, ↑ English- Respondents who 

20081 correlates of or endoscopy ever spoken at metropolitan language reported speaking 

screening home; statistical area proficiency English at home 

Cross- among all 4 foreign- or (rurality), were more likely to 

sectional, major US US-born region of US, ↑ US-born report being 

retrospective, racial/ethnic income, screened than 

national categories education, those who did not 

(non-Hispanic insurance, (AOR, 1.84; 95% 

MEPS, 2001- white, Asian, usual source of CI, 1.52-1.33 for 

2005, black, and care, self-rated combined 

combined Hispanic health screening with 

with NHIS, individuals) FOBT or 

2000-2004, endoscopy) 

≥ 50 years 

Those born in the 

N = 22,973 US were also more 

likely to be 

Good screened than 

those who were not 

(AOR, 1.16; 95% 

CI, 1.01-1.33) 

65 
Table 15. Studies of the association between acculturation and CRC screening (continued) 

Author, Year 

Study 

Design 

Population Potential Variables 

Setting Primary Outcome of Confounders/ Associated 

Sample Size Interest for Review Predictors Modifiers with CRC 

Quality Study Aims Examined Reported Screening Results (95% CI) 

Jerant, et al., There were no 

2008141 differences in 

(continued) screening rates 

among other 

N = 22,419 groups of 

Hispanics in terms 

Good of their reported 

screening 

Shah, 2006121 Examine Not having had Acculturation Marital status, No Adjusted rates for 

whether low FOBT (at home) in (i.e., English age, education, difference in not being screened 

National acculturation is past year and not language income screening with low English 

cross a risk factor for having had lower usage) in rates based language usage as 

sectional underutilization endoscopy in past 5 tertiles: low, on language the referent: 

survey; of CRC years moderate, usage 

NHIS, 2000 screening high Moderate: AOR, 

examinations 0.92; 95% CI, 

Hispanics in the Hispanic 0.60-1.42 

age 50-80 population 

High: AOR, 0.75; 

N = 1,163 95% CI, 0.45-1.25 

Fair 

Shih et al., Examine Ever been screened Foreign-born Age, gender, ↓ Foreign- Foreign-born 

2008120 factors by FOBT or by years in race/ethnicity, born and respondents living 

associated endoscopy US geographic living in US in US ≤10 years 

Cross- with CRC (self-report) (short = < 10 region, urban ≤ 10 years were less likely 

sectional, screening of years; vs. rural or ≥ 15 than US-born nonretrospective, US- and moderate = years Hispanic whites to 

national foreign-born 10-14 years; be screened for 

groups long CRC (AOR 0.46; 

NHIS, 2000, duration = 95% CI, 0.29­

≥ 50 years ≥ 15 years) 0.71), as were 

foreign-born 

N = 12,179 respondents living 

in US for 15 years 

Good or more (AOR 

0.58; 95% CI, 

0.51-0.67; 

P ≤ 0.001) 

Schumacher Investigate Colonoscopy or FS in English- Age, location, ↓ American Respondents 

et al., 2008122 predictive past 5 years (self- language gender, Indians speaking only 

factors report) proficiency education, using native native languages 

Cohort study, associated (language family history languages at home were less 

several states with receiving spoken at of cancer, at home likely to have 

(Alaska, each of the home) family history obtained CRC 

Southwest cancer of CRC, smoke screening than 

United screening tests cigarettes in those speaking 

States) past 5 years, English at home 

history of (AOR, 0.50; 95% 

chronic CI, 0.33-0.76) 

66 
Table 15. Studies of the association between acculturation and CRC screening (continued) 

Author, Year 

Study 

Design 

Population Potential Variables 

Setting Primary Outcome of Confounders/ Associated 

Sample Size Interest for Review Predictors Modifiers with CRC 

Quality Study Aims Examined Reported Screening Results (95% CI) 

Schumacher medical Those speaking 

et al., 2008122 condition, English and native 

(continued) language, languages at home 

residency, were also less 

Baseline income, other likely to have 

survey, 2004- screening tests received CRC 

2007, screening (AOR, 

American 0.65; 95% CI, 

Indian/Alaska 0.50-0.85) 

Natives, 50+ 

years 

N = 2,779 

Fair 

Sun et al., Investigate FOBT only in past Years of US Age, gender, ↑ Years in Years living in US 

2004118 factors year, FOBT + FS in residency marital status, US was a predictor of 

associated past 5 years, or no (< 10 years; home owner, FOBT only 

Cross- with CRC test 10-19 years; ethnicity, years (AOR, 0.64; 95% 

sectional, screening (claims) ≥ 20 years) at residence, CI, 0.41-0.99; 

retrospective, among senior education, P < 0.05); or for 

Local Chinese income, either FOBT only 

Americans insurance, or FOBT + FS 

Chinese employment, (AOR, 0.54; 95% 

Americans, family history CI, 0.64-0.94) 

1999-2000, 3 of CRC, 

senior worries or 

centers in fears, 

New York perceived 

City, ≥ 50 susceptibility, 

years self-efficacy, 

social 

N = 203 influence, 

intention, 

Fair efficacy of 

screening 

Wong et al., Factors related FOBT in past year or Foreign-born Ethnic group, ↓ Living in Foreign-born 

20052 to screening endoscopy in past 10 and years age, gender, US for < 15 respondents living 

rates among years, or both living in US education, years in US for < 15 

Cross- Asian (self-report) (< 15 years in marital status, years were less 

sectional, Americans the US or household size likely to have ever 

retrospective, compared with ≥ 15 years in and income, received CRC 

State non-Latino US) years in US, screening (AOR, 

whites comorbidities, 0.48; 95% CI, 

California English 0.32-0.71) or to be 

Health language up-to-date with 

Interview proficiency, screening (AOR, 

Survey, 2001, family history 0.58; 95% CI, 

≥ 50 years of CRC 0.40-0.82) 

67 
20052 

Table 15. Studies of the association between acculturation and CRC screening (continued) 

Author, Year 

Study 

Design 

Population 

Setting 

Sample Size 

Quality Study Aims 

Primary Outcome of 

Interest for Review Predictors 

Examined 

Potential 

Confounders/ 

Modifiers 

Reported 

Variables 

Associated 

with CRC 

Screening Results (95% CI) 

Wong et al., 

(continued) 

N = 1,771 

Asian 

Americans 

Fair 

AOR, adjusted odds ratio; BRFSS, Behavioral Risk Factor Surveillance Survey; CI, confidence interval; CRC, colorectal cancer; FOBT, fecal 

occult blood test; FS, flexible sigmoidoscopy; MEPS, Medical Expenditure Panel Survey; NHIS, National Health Interview Survey; US, United 

States. 

* Arrow symbols (↓or ↑) are provided as a quick reference point of overall findings and represent the association reported between each variable 

and CRC screening. 

these factors may be important for any race or ethnicity, the studies we consider here examined 

them specific to non-white Hispanics,1,121,141,149,161 Asians,118 or both Hispanics and Asians;2,147 

one study included all racial/ethnic groups by whether or not they were born in the United 

States;120 and one focused on American Indians and Alaska Natives.122 Six of the nine studies are 

based on nationally representative samples of respondents collected through self-reported survey 

data.1,120-121,141,147,149,161 One study was based on self-reported data from across several states,122 

one on data from a state-based survey,2 and one on locally based claims data from three senior 

centers in New York City.118 All but one121 of the nine studies included those 50 years of age or 

older in their sample. 

The operationalization of CRC screening differed across the nine studies as follows: 

•	 Two studies included those who had FOBT in the past year or endoscopy in the past 10 

years among those currently screened;2,161 

•	 Two studies defined screening as FOBT in the past year and either FS or protoscopy in 

the past 5 years;118,147 

•	 One study (with varied results described in two articles) defined screening as having 

FOBT in the past 2 years or ever having had an endoscopy;1,141 

•	 One study defined screening as those who had ever had FOBT or endoscopy;120 

•	 One study defined screening as having had either colonoscopy or FS in the past 5 

years;122
 

•	 One study defined screening as a FOBT in past year, FS in past 5 years, or colonoscopy 

in past 10 years; 149 and, 

•	 One study used a lack of screening as their outcome such that those who had no FOBT in 

the past year or no endoscopy in the past 5 years were considered to be not screened for 

CRC.121 

Overview of results. Of the nine studies (reported in 10 articles), four reported findings 

specific to whether respondents were foreign- or US-born;2,118,120,147 three examined the 

68 
relationship between English-language proficiency and screening;122,141,161 and three examined 

both place of birth and English-language proficiency.1,121,149 

With respect to being foreign-born or years living in the United States, we considered three 

studies with findings specific to place of birth, three with findings specific to the number of years 

living in the United States,2,118,120 and four with information as to whether the respondent 

reported being born in the United States.1,120,147,149 For place of birth, two studies found that 

those born in the US were more likely to have been screened than those who were foreign 

born134 (or foreign born were less likely to be screened if living in US 10 years or less119), 

whereas another found no differences in screening based on place of birth once other factors 

were controlled. 114 Four studies also reported a negative association between number of years 

living in the United States and being up-to-date with CRC screening.1-2,118,120,147,149 

Two studies presented findings specific to Asian Americans. In one analysis of a 

convenience sample of Chinese Americans, as a person’s years in the United States increased so 

did their odds of being screened (AOR, 0.64; P < 0.05).118 Another study based on data collected 

through the 2001 CHIS reported that Asian Americans living in the United States less than 15 

years were less likely to be up-to-date with screening than those living here longer than 15 years 

(AOR, 0.58).2 

Two additional studies not included here (because exploring acculturation was not a specific 

aim of their work) reported that the years of living in the United States made no difference in 

terms of CRC screening.114,163 

With respect to English-language proficiency, we considered four studies.1,121-122,141,161 All 

but one150 found an association between this factor and CRC screening. The fourth study used a 

scale for acculturation that was based on English language usage (e.g., language most often 

spoken or read, everyday usage via TV, radio); it found no difference in screening rates once 

findings were adjusted for socioeconomic status and access to care variables.121 One of these 

four studies presented findings from American Indian and Alaska Natives across several states 

that demonstrated an association between CRC screening and either speaking only native 

languages at home (AOR, 0.50) or speaking a combination of native language and English at 

home (AOR, 0.65; 95% CI, 0.50-0.85).122 A similar relationship was found for any respondents 

of the national study of 2001-2005 MEPS and 2000-2004 NHIS data; speaking English at home 

was significantly associated with increased CRC screening (AOR, 1.84; 95% CI, 1.52-1.33).1 

Overall, Latinos who were interviewed in Spanish were less likely to report screening than nonHispanic whites (AOR, 0.57, or more likely to not be screened with AOR of 2.5).149,161 

Income. Study characteristics. Most studies included household income as a potential 

confounding variable; we highlight two studies, both rated fair quality, here because a primary 

study aim was to examine the association between income and screening rates (Table 16).114,123 

One study relied on national data from the 2002 BRFSS constructed for metropolitan or 

micropolitan statistical areas (MMSA) to examine the predictive value of area poverty rates on 

CRC screening.123 The other study presented local data collected through a Community Health 

Survey of New York City residents.114 Both studies relied on self-reported data from respondents 

50 years of age or older.114,123 One study assessed the outcome of CRC screening by respondent 

reports of whether they had obtained an FOBT in the past year or a endoscopy in the past 5 

years.123 The other study defined CRC screening as having received FOBT in the past year, FS in 

the past 5 years, or colonoscopy in the past 10 years.114 

Overview of results. Similar to the three national overview studies,21,46,151 both of these 

studies found an association between income and screening rates; persons with lower incomes 

were less likely to receive any CRC test, and those with higher incomes were more likely to be 

screened.114,123 

69 
Table 16. Studies of the association of income with CRC screening 

Author, Year 

Study 

Design 

Population 

Setting 

Sample Size 

Quality Study Aims 

Primary Outcome of 

Interest for Review 

Predictors 

Examined 

Potential 

Confounders/ 

Considered 

Variables 

Associated 

with CRC 

Screening* 

Results (95% 

CI) 

Shootman et 

al., 2006123 Analyze 

contextual 

Any test (FOBT with 

past year, either FS or 

MMSA; 

household 

Gender, age, 

race/ethnicity 

↓ residing in 

high poverty 

People residing 

in low income 

effect of area colonoscopy in past 5 income areas area were less 

Cross- poverty rate years (self-report) likely than those 

sectional, on never in higher 

retrospective, having been income areas to 

national screened have never 

received 

BRFSS FS/colonoscopy 

(2002), for 98 (AOR, 1.10; 

MMSA, ≥ 50 95% CI, 1.01­

years 1.19) or FOBT 

(AOR, 1.19; 

N = 118,000 95% CI, 1.12­

1.27) 

Fair 

Thorpe et al., 

2005114 

Crosssectional/ 

retrospective, 

local 

Community 

Health 

Survey, New 

York City 

residents 

≥ 50 years 

N = 3,606 

Fair 

Examine 

characteristics 

of people 

undergoing 

screening 

within 

guidelines 

Any test per 

guidelines (FOBT 

within past year, FS in 

past 5 years, or 

colonoscopy in past 

10 years) 

(self-report) 

Personal 

household 

income; 

neighborhood income 

level (% of 

families ≤

200% federal 

poverty level, 

if 45% or 

more met 

this 

definition, 

neighborhood was 

identified as 

low income) 

Age, race, 

ethnicity, 

gender, 

personal risk 

factors 

(current 

smoking, 

physical 

inactivity), 

access to 

care, 

insurance, 

regular source 

of care 

↓ Household 

income < 

$25,000c

 for 

any test and 

for 

colonoscopy 

↓ Neighborhood income 

(medium) for 

any test 

Groups with 

lowest likelihood 

of screening 

were poor 

(AOR, 0.68 for 

any test: 95% 

CI, 0.54-0.85) 

Living in a 

medium-income 

(vs. poor- or 

high-income) 

neighborhood 

made 

respondents 

less likely to 

receive any test 

(AOR, 0.76; 

95% CI, 0.61­

0.93) 

AOR, adjusted odds ratio; BRFSS, Behavioral Risk Factor Surveillance System; CI, confidence interval; CRC, colorectal cancer; 

FOBT, fecal occult blood test; FS, flexible sigmoidoscopy; MMSA, metropolitan and micropolitan statistical area. 

* Arrow symbols (↓or ↑) are provided as a quick reference point of overall findings and represent the association reported 

between each variable and CRC screening. 

These studies also add findings at both the neighborhood and MMSA levels by suggesting 

that even living in lower-income areas predicts CRC screening rates. People residing in low 

MMSAs were less likely than those in high-income MMSA to receive an endoscopy (AOR 1.10) 

or FOBT (AOR 1.19);123 respondents living in a medium-income neighborhood (versus a poor or 

a high-income neighborhood) were less likely to receive any test (AOR, 0.76).114 

Of the other studies that included income level as a variable in their final multivariate 

analysis, 10 found either that persons with low income were less likely than those with high 

income to receive screening,1-2,42,107,120,122,126,130,150,156 or that higher-income respondents were 

more likely than lower-income ones to have obtained screening.120,150 One study that focused on 

70 
exploring racial differences in screening found that controlling for SES (i.e., education, income) 

in a nationally representative sample of Medicare beneficiaries eliminated any differences in 

rates. 129 An additional six studies reported no difference in screening rates by income 

level.55,108,156-157,160,163 

Insurance status. Study characteristics. We include seven studies, one rated as good 

quality56 and the rest rated as fair quality, in the highlighted results specific to insurance 

status107,113-114,124,138,160 (Table 17). Of these, four are based on national samples of respondents 

or patients;56,113,124,138 two are based on state-level samples;107,160 and one was based on a local 

sample of New York City residents.114 All but one study relied on self-reported data; the 

exception relied on a national sample of Medicare beneficiaries for their analysis.138 The 

populations of interest for three studies was those 50 years or age of older;107,114,160 two studies 

focused on those ages 50-64 years;56,113 and two relied on samples of people 65 years or 

older.124,138 

In terms of the outcome of screening, definitions varied 

•	 Three studies defined CRC screening as FOBT in the past year, FS in the past 5 years, 

or colonoscopy in the past 10 years;107,114,160 

•	 One defined being screened as having an FOBT in the past year or an endoscopy in 

the past 10 years;113 

•	 One defined the outcome as having had an FOBT in the past 2 years or an endoscopy 

in the past 5 years;124 

•	 One defined being screened as any CRC test in the past year;138 and 

•	 One defined being screened as having had an FOBT in the past year.56 

Overview of results. Four of the seven studies compared screening rates according to 

whether respondents reported having any insurance or no insurance.56,113-114,160 All four studies 

reported results similar to those from the three overview studies;21,46,151 those without insurance 

were far less likely to report being screened than those with any type of insurance.56,113-114,160 

This relationship remained when data from of national samples of survey respondents in 2000 

were compared with those in 2005; females showed no change from 2000 to 2005 in screening 

rates (AOR, -1.3), and males showed only a slight increase in screening over time (AOR, 3.0).113 

Other studies also reported similar findings. Generally, for any tests, the uninsured were less 

likely to be up-to-date with screening than those with some insurance.2,116,128 

Of the three studies that focused on the association between different types of insurance coverage 

and CRC screening, one focused on two groups, one comprising “dual” recipients of both 

Medicare and Medicaid and the other nondual Medicare recipients.138 Another explored how 

those with managed care coverage compared with those having other insurance coverage among 

a Medicare-enrolled population (i.e., 65 years or older),124 and a third examined these 

relationships in those 50 years or older.107 Another study (not in summary table) compared type 

of insurance among a sample of low-income women residing in Washington, DC and reported 

(based on self-reports) that those participating in Health Maintenance Organizations (HMO) 

were more likely than others to be current with screening (AOR, 6.39; 95% CI, 2.05, 19.9 for 

private HMO; P < 0.01).128 

These studies reported two main results. Persons who are dual recipients were less likely than 

others to receive any of the CRC tests (i.e., FOBT, FS, colonoscopy);138 those in a managed care 

Medicare plan were more likely to be screened per guidelines than those with any other types of 

insurance (Medicare or otherwise).107,124 

71 
Table 17. Studies of insurance status as a predictor of CRC screening 

Primary Outcome 

of Interest for 

Author, Year Review 

Study Design 

Population 

(i.e., screening or 

followup after Potential Variables 

Setting 

Sample Size 

Quality 

Study 

Aims 

abnormal FOBT; 

completion rates 

or discussions) 

Predictors 

Examined 

Confounders/ 

Modifiers 

Reported 

Associated 

with CRC 

Screening Results (95% CI) 

Cairns et al., 

200656 Examine 

the role of 

FOBT within the 

past year 

Insurance 

coverage vs. 

Age, insurance, 

whether there 

↓ uninsured Uninsured were 64% 

less likely to be 

communi­ (self-report) no coverage is a usual screened than 

Cross-sectional, cation provider, the insured (AOR, 

national factors and gender, 0.36; 95% CI, 0.241– 

insurance race/ethnicity, 0.536; P < 0.001) 

HINTS, 2002­ on CRC annual 

2003, 50-64 screening. household 

years income, 

employment, 

N = 1,253 rural vs. urban 

county, 

Good education 

de Bosset, et 

al., 2008160 Examine 

whether 

FOBT within past 

year and/or lower 

Insurance 

coverage vs. 

Gender, age, 

education, 

↓ uninsured 

males 

Insured males were 

more likely to report 

self- endoscopy within no coverage income, CRC screening than 

Cross-sectional, reported past 5 years employment, uninsured males 

state insurance (self-report) having seen (AOR, 2.02; 95% CI, 

coverage physician in 0.96-4.23) 

BRFSS, 2005, was previous year 

Virginia associated For females, there 

residents 50 with CRC was no effect of 

years or older screening insurance coverage 

(AOR, 0.86; 95% CI; 

N = 2,887 0.34-1.93) 

Fair 

Koroukin et al., 

2006138 Assess 

disparities 

Any test code 

(colonoscopy, FS, 

Insurance 

status: 

Dual 

beneficiary 

↓ dualeligibles Use of CRC 

screening services 

in CRC FOBT) within the Medicare dual status, age, decrease if dual 

Cross-sectional, screening past year (claims) eligible vs. race, sex enrollment in 

national between non dual- Medicare-Medicaid: 

Medicare elderly eligible FOBT (AOR, 0.48; 

Denominator dual 95% CI, 0.45-0.51), 

File, 1999, ≥ 65 Medicare- FS (AOR, 0.55; 95% 

years Medicaid 

enrollees 

CI, 0.49-0.61), FS or 

colonoscopy (AOR, 

N = 23 million (duals) and 0.60; 95% CI, 0.54­

(2.5 million 

duals, 20.2 

non-duals. 0.67), 

colonoscopy (AOR, 

million 0.85; 95% CI, 0.80­

nonduals) 0.89) 

Fair 

72 
Table 17. Studies of insurance status as a predictor of CRC screening (continued) 

Primary Outcome 

of Interest for 

Author, Year Review 

Study Design 

Population 

Setting 

Sample Size 

Quality 

Study 

Aims 

(i.e., screening or 

followup after 

abnormal FOBT; 

completion rates 

or discussions) 

Predictors 

Examined 

Potential 

Confounders/ 

Modifiers 

Reported 

Variables 

Associated 

with CRC 

Screening Results (95% CI) 

Schneider et al., 

2008124 Assessed 

whether 

Any test (2 years for 

FOBT or 5 years for 

Insurance 

status 

Age, gender, 

race, Hispanic 

↑ MMC MMC (52.9%) was 

more likely than 

benefi­ colonoscopy or FS) categories: origin, supplemental 

Cross-sectional, ciaries in (self-report) MMC; FFS education, insurance groups 

retrospective, MMC SUPP; FFS marital status, (FFS SUP) (50.7%, 

national plans were NO SUPP annual income, P = 0.15) to receive 

more likely metro area CRC screening, but 

Medicare than those residency time-interval 

Current in appropriateness was 

Beneficiary traditional similar between 

Survey, 2000, FFS groups (no 

≥ 65 years insurance 

to receive 

confidence intervals 

provided) 

N = 10,173 CRC 

screening Beneficiaries in MMC 

Fair and were more likely than 

whether those in 

type of the FFS SUPP group 

insurance to receive intervalwas appropriate FOBT 

associated (36.3% vs. 32.1%; 

with use of P = 0.013), but less 

specific likely to 

screening receive an intervalstrategies appropriate invasive 

screening procedure 

(35.9% vs. 40.8%; 

P < 0.001) 

Trivers, et al., 

2008113 Determine 

whether 

Any test (FOBT 

within past year, FS 

Insurance 

status 

Age, gender, 

race, ethnicity, 

↑ private 

health 

For both males and 

females with private 

progress or colonoscopy in categories; poverty ratio, insurance insurance, there was 

Cross-sectional, was made past 10 years) (self­ public, private, insurance, a significant increase 

retrospective, between report) or none education, in screening from 

national 2000 and region, years in 2000 to 2005 

2005 in US (change over time for 

NHIS, 2000 reducing male: OR, 6.7; 95% 

compared with CRC CI, 3.4-9.9 and for 

2005, 50-64 screening female: OR, 10.0; 

years disparities 95% CI, 7.0-13.0) 

by race, 

N = ethnicity, For females with no 

6,020 in 2000; income, insurance, there was 

6,706 in 2005 and no change from 2000 

insurance to 2005 in screening 

Fair status. rates (AOR, -1.3; 

95% CI, -7.1-4.6) 

and for male, there 

was only a slight 

increase in screening 

over time (AOR, 3.0; 

95% CI, -3.9 to 9.8) 

73 
Table 17. Studies of insurance status as a predictor of CRC screening (continued) 

Primary Outcome 

of Interest for 

Author, Year Review 

Study Design 

Population 

Setting 

Sample Size 

Quality 

Study 

Aims 

(i.e., screening or 

followup after 

abnormal FOBT; 

completion rates 

or discussions) 

Predictors 

Examined 

Potential 

Confounders/ 

Modifiers 

Reported 

Variables 

Associated 

with CRC 

Screening Results (95% CI) 

Thorpe, et al., 

2005114 Analysis of 

individualAny test (colonoscopy in 

Insurance 

status 

Age, race, 

birthplace, 

↓ uninsured Any timely CRC 

screening test: 

and past 10 years, gender, Medicaid or 

Cross-sectional, neighbor- FOBT in past year, education, Medicare (AOR 1.02; 

retrospective, hood-level and FS in past 5 household 95% CI, 0.81-1.28); 

local factors years) (self-report) income, uninsured (AOR 

associated neighborhood 0.31; 95% CI, 0.20­

Community with colon income 0.48) 

Health Survey, cancer 

2003, New York screening Colonoscopy in past 

City residents, practices 10 years: Medicaid 

≥ 50 years or Medicare (AOR 

0.89; 95% CI, 0.71­

N = 3,606 1.13); uninsured 

(AOR 0.39; 95% CI, 

Fair 0.23-0.65) 

Zapka et al., 

2002107 Assess the 

role of 

Any test 

(colonoscopy or 

Insurance 

status 

Gender, race, 

education, 

↑Medicare 

non-HMO 

Medicare HMO 

participants were 

insurance barium enema categories: for employment participants somewhat more 

Cross-sectional, status, within 10 years, FS those 50-64 status, income, likely to be currently 

state type of within 5 years, and years-- private marital status, tested than Medicare 

plan, FOBT in the past (non-HMO); family history of non-HMO 

Community frequency year) (self-report) HMO; public, CRC, participants (AOR, 

Health Survey, of uninsured; perceived 1.83; 95% CI, 0.91-

1998, preventive For those health status 3.71) 

Massachusetts health 65+- nonresidents, ≥ 50 visits, and HMO There was an 

years provider 

recomMedicare; Medicare 

interaction between 

insurance status and 

N = 1,002 mendation HMO; duals respondents who 

on believed their 

Fair utilization insurance did, or did 

of CRC not pay for CRC 

screening tests 

tests 

AOR, adjusted odds ratio; BRFSS, Behavioral Risk Factor Surveillance System; CI, confidence interval; CRC, colorectal cancer; FFS, fee-forservice; FFS + NO SUPP, fee-for-service Medicare + no supplemental insurance; FFS + SUPP, fee-for-service Medicare + supplemental 

insurance; FOBT, fecal occult blood test; FS, flexible sigmoidoscopy; HINTS, Health Information National Trends Survey; HMO, health 

maintenance organization; MMC, Medicare managed care; N, number; RR, relative risk. 

*Arrow symbols (↓or ↑) are provided as a quick reference point of overall findings and represent the association reported between each variable 

and CRC screening. 

Overall, 13 additional studies with insurance status as a variable in their final adjusted 

logistic regressions reported that those who were uninsured were less likely than those insured to 

report current CRC screening.1-2,42,111,116,120,126,130,134,146,156-157,163 Three other studies that included 

insurance status in such analyses found no difference in CRC screening by this variable.109,132,137 

Access to care. Study characteristics. Access to care is defined in most studies as having a 

usual (or regular) source of care and visiting that provider at least once within the past year. Most 

studies included these variables as control or potential confounding variables; here we present 

74 
more detailed information on four studies that specifically highlighted the relationship between 

access-to-care variables and CRC screening (Table 18).108,133-134,163 

One study, rated as good quality, based results on the 2002-2003 HINTS;133 the others, all 

rated as fair quality, presented either regional134,170 or state-level findings.163 All four studies 

Table 18. Studies of the association of access to care with CRC screening 

Author, Year 

Study 

Design 

Population 

Setting 

Sample Size 

Quality 

Study 

Aims 

Primary Outcome of 

Interest for Review 

(i.e., screening or 

followup after 

abnormal FOBT; 

completion rates or 

discussions) 

Predictors 

Examined 

Potential 

Confounders/ 

Considered 

Variables 

Associated 

with CRC 

Screening* 

Results (95% 

CI) 

McQueen et 

al., 2006133 Examine 

correlates 

Any test (endoscopy 

in the last 10 years or 

Number of 

physician 

Demographics, 

access, health 

↑ Visit 

physician 

Those who had 

visited a 

of test use FOBT in the last year) visits in past status, health regularly physician 1 or 

Cross- by gender (self-report) year; having behaviors more times in the 

sectional, a usual ↓ No usual previous year 

national source of source of care were more likely 

care to be screened 

HINTS, 2002­ by endoscopy 

2003, 50+ than those with 

years no visits in the 

prior year (AOR 

N = 2,686 5.12; 95% CI, 

2.54-10.29 for 

Good males and OR 

4.89; 95% CI, 

1.79-13.37 for 

females; P < 

0.05) 

“Not having a 

doctor” was 

associated with 

not being 

screened for 

CRC in both 

males (AOR, 0.1; 

95% CI, 0.0-0.5 

for FOBT and 

OR, 0.5; 95% CI, 

0.1-1.9 for 

endoscopy) and 

females (AOR, 

0.2; 95% CI, 0.1­

0.8 for FOBT and 

OR, 0.5; 95% CI, 

0.2-1.4 for 

endoscopy) 

75 
Table 18. Studies of the association of access to care with CRC screening (continued) 

Author, Year 

Study 

Design 

Population 

Setting 

Sample Size 

Quality 

Study 

Aims 

Primary Outcome of 

Interest for Review 

(i.e., screening or 

followup after 

abnormal FOBT; 

completion rates or 

discussions) 

Predictors 

Examined 

Potential 

Confounders/ 

Considered 

Variables 

Associated 

with CRC 

Screening* 

Results (95% 

CI) 

Etzioni et al., 

2004163 Examine 

individualAny test (FOBT within past year, FS or 

Access to 

care 

Age, gender, 

race, marital 

↓ Uninsured 

individuals with 

Uninsured 

respondents with 

level colonoscopy in past 5 combined status, income, and without a usual source of 

Cross- variables years) (self-report) as a education, self- usual source of care were less 

sectional, associated composite reported health care likely to receive 

state with of insurance status, number CRC testing than 

screening status with of visits to ↑ Number of those in any of 

CHIS, 2001, whether physician in physician visits the other 

50+ years respondent last 12 months, insurance 

reported a percent of life categories with 

N = 22,343 usual lived in the US, usual source of 

source of English care (RR, 0.61; 

Fair care. proficiency 95% CI, 0.53­

Insurance 0.69 for 50-64 

categories years; RR, 0.62; 

included: 95% CI, 0.37­

< 65 years: 0.92 for 65+) 

employerbased, Uninsured with 

private/self­ no usual source 

purchased, of care were less 

public, likely to be 

uninsured screened than 

65+ years: any of the other 

Medicare + groups of 

supplement, individuals (RR, 

Duals, 0.32; 95% CI, 

Medicare 0.23-0.43 for 50­

only, 64; RR, 0.08; 

uninsured; 95% CI, 0.00­

Number of 1.21 for 65+) 

physician 

visits in past Respondents 

year who reported 

visiting a 

physician 1 or 

more times in 

past year were 

more likely to 

report being 

current with 

screening (RR 

range 1.41-1.77) 

76 
Table 18. Studies of the association of access to care with CRC screening (continued) 

Author, Year 

Study 

Design 

Population 

Setting 

Sample Size 

Quality 

Study 

Aims 

Primary Outcome of 

Interest for Review 

(i.e., screening or 

followup after 

abnormal FOBT; 

completion rates or 

discussions) 

Predictors 

Examined 

Potential 

Confounders/ 

Considered 

Variables 

Associated 

with CRC 

Screening* 

Results (95% 

CI) 

Matthews et 

al., 2007134 Identify 

indicators 

FOBT within past 

year, FS in past 5 

Regular 

physician 

Gender, age, 

race, education 

↑ Visit 

physician 

Respondents 

who reported 

of up-to­ years, or colonoscopy visits regularly visiting a 

Cross- date CRC in past 10 years physician 

sectional, screening (self-report) regularly were 

regional more likely to 

report being 

Survey current with 

administered screening (AOR 

to 5-county 2.02; 95% CI, 

region in 1.49-2.74) 

Midwest, 

2005, 50-79 

years 

N = 1,033 

Fair 

Young et al., Identify Any CRC test (FOBT Saw a Age, gender, ↑ Visit with Respondents 

2007108 variables in past year, FS or doctor or race/ethnicity, provider in past who reported 

Associated double-contrast other health marital status, year visiting a doctor 

Cross- with barium enema in past care education, or other health 

sectional, screening 5 years, colonoscopy provider in employment, No difference provider in past 

regional in past 10 years) past year; income, patient based on year were more 

geographic request for proximity to likely to be up-toRDD survey, proximity to screening, health facility date on CRC 

residents in a facility perceived risk, screening than 

eastern that offers family history others (AOR, 

Colorado, testing 1.29; 95% CI, 

2005, 50 1.21-1.38) 

years or older 

Up-to-date 

N = 1,005 screening for 

(weighted those living in an 

sample) area with a 

health care 

Fair facility were no 

different than 

those without a 

health facility 

(range of P 

values = 0.38­

0.78) 

CHIS, California Health Interview Survey; CI, confidence interval; CRC, colorectal cancer; FOBT, fecal occult blood test; HINTS, Health 

Information National Trends Survey; OR, odds ratio; RDD, random digital dialing; RR, relative risk. 

* Arrow symbols (↓or ↑) are provided as a quick reference point of overall findings and represent the association reported between each variable 

and CRC screening. 

relied on self-reported data for their analysis.108,133-134,163 The two regional studies relied on 

survey data collected in 2005 from a five-county region in the Midwest134 or data collected in 

2005 across a region in the state of Colorado.108 The state-based study used CHIS data.163 One 

study included respondents ages 50-79 years;134 the other three included those 50 years or 

older.108,133,163 

77 
To assess the CRC screening outcome, two studies used FOBT in the past year or endoscopy 

in the past 10 years,108,133 one study defined CRC screening as having obtained FOBT within the 

past year or endoscopy in the past 5 years,163 and the fourth defined the outcome as FOBT in the 

past year, FS in the past 5 years, or colonoscopy in the past 10 years.134 

Overview of results. As with the three overview studies,21,46,151 usual source of care 

predicted CRC screening for both a study of multiple factors influencing screening in a national 

sample133 and a state-based study of the relationship between screening and having a usual 

source of care combined with insurance status.163 The national study found that not having a 

usual source of care was associated with not being screened among both males and females 

(AOR range, 0.1-0.5).133 In the state-based study, uninsured respondents with no usual source of 

care were less likely to be screened than any of the other groups of individuals in their sample 

(RR, 0.32 for 50-64; RR, 0.08 for 65+).163 

Several other studies found similar results: usual source of care was consistently associated 

with higher rates of CRC screening.1-2,42,56,107-108,111,120,128,130,157 A recently published study of the 

2004 BRFSS also reported a strong association between screening and having at least 1 personal 

health care provider (AOR, 3.95; 95% CI, 2.58-4.41).155 Another study reported no difference in 

CRC screening and having a regular provider.124 

Similar to the three overview studies,21,46,151 other included studies consistently reported a 

strong association between the frequency of visits to a physician and CRC screening. Authors of 

the national study reported that one or more physician visits in the prior year was associated with 

endoscopic screening (5.12; 2.54-10.29 for males and 4.89; 1.79-13.37 for females; P < 0.05).133 

The three other studies also found that the number of physician visits was strongly associated 

with CRC screening. Seven other studies in this review reported the same 

association.2,55,107,126,132,137,158,166 

Personal health and risk factors. Study characteristics. A total of nine studies, all of which 

we rated as fair quality, are included in the summary table (Table 19) for personal health or risk 

factors associated with CRC screening.55,108,114,126,132,137,145,157,166 Personal health factors are 

characteristics from the person’s family history or personal health history (e.g., family CRC 

diagnosis, personal prior polyp removal, screening behavior with regard to other cancers, general 

health status) that would place them at increased risk for CRC and/or may be related to healthy 

behaviors that could influence the extent to which they obtain regular CRC screenings. Risk 

factors for health problems possibly related to CRC screening include smoking, sedentary 

lifestyle, poor eating habits, obesity, and any factor that may place a person at increased risk for 

developing CRC. 

For this set of variables, we have included one study that specifically evaluated the 

association between CRC screening and family history of CRC,108 two studies that included 

other cancer screenings,137,157 one study specific to general health status,55 and five studies 

specific to risk factors (i.e., obesity/overweight, smoking, or physical inactivity).114,126,132,145,166 

Eight studies relied on cross-sectional, retrospective data collected through a survey, including 

four of which were based on national samples;55,126,145,157 two were based on state samples;132,137 

one reported on a regional sample;108 and one focused on a city-based or local sample.114 The 

remaining study presented findings from medical chart reviews of 22 primary care provider 

(PCP) practices in the states of New Jersey and Pennsylvania.166 

78 
Table 19. Studies of the association of personal health/risk factors with CRC screening 

Author, 

Year 

Study 

Design 

Population 

Setting 

Sample 

Size 

Primary 

Outcome of 

Interest for Predictors 

Potential 

Confounders 

Variables 

Associated 

with CRC 

Quality Study Aims Review Examined Considered Screening* Results (95% CI) 

Family History of CRC 

Young et al., 

2007108 Identify 

variables 

Any CRC 

test (FOBT in 

Family history 

of CRC 

Age, gender, 

race/ethnicity, 

↑ Family history 

of CRC 

Respondents with a 

family history of CRC 

associated past year, FS marital status, were more likely than 

Cross- with or double- education, others to have received 

sectional, screening contrast employment, colonoscopy (AOR, 

regional barium income, last MD 2.61; 95% CI, 1.86-

enema in visit, patient 3.68) and be up to date 

RDD survey, past 5 years, request for on any CRC test (AOR, 

residents in colonoscopy screening, 1.74; 95% CI, 1.20­

eastern in past 10 perceived risk, 2.53) 

Colorado, years) residence by zip 

2005, ≥ 50 code 

years 

N = 1,005 

(weighted 

sample) 

Fair 

Other Cancer Screenings 

Carlos et al., 

2005157 Understand 

screening 

FOBT within 

past year, FS 

Mammogram 

(within past 

Age, race, 

educational 

↑ regular Pap 

smear and 

Increased screening 

rates with females who 

behaviors or year) and Pap level, mammogram reported adherence to 

Cross- among colonoscopy smear (within employment mammograms (AOR, 

sectional, female in past 5 past year) status, income, ↓ Preceived 2.42; P < 0.01) and 

national years self-reported ‘good’ health Pap smears (AOR, 

(self-report) general health, status 1.70; P < 0.01) 

BRFSS, smoking, health 

2001, insurance, Females who 

females ≥ 50 personal doctor perceived their health 

years as good were less 

likely to adhere to CRC 

N = 52,478 screening than other 

females (AOR, 0.79; 

Fair 95% CI, 0.66-0.93; 

P < 0.01) 

79 
Table 19. Studies of the association of personal health/risk factors with CRC screening (continued) 

Author, 

Year 

Study 

Design 

Population 

Setting 

Sample 

Size 

Primary 

Outcome of 

Interest for Predictors 

Potential 

Confounders 

Variables 

Associated 

with CRC 

Quality Study Aims Review Examined Considered Screening* Results (95% CI) 

Lemon et 

al., 2001137 Examine 

relationship 

FOBT in past 

year, FS in 

Mammogram 

(within past 

Gender, 

education, 

↑ Other cancer 

screening 

Males and females who 

were currently screened 

of personal past 5 years, year) for insurance behavior for for PSA or 

Cross­ characteristi colonoscopy female; PSA status, checkup males and mammography, 

sectional, cs, health in past 10 (within past at least every female respectively, were more 

retrospec­ and lifestyle years, or year) for male; year likely to report being uptive, state behaviors, double- smoking to-date with CRC 

level and cancer contrast (never, former, screening (AOR, 4.40; 

screening barium or current); use 95% CI, 2.94-6.58; 

State-based practices to enema in of any type of P < 0.001) 

telephone current past 10 years vitamin 

survey of CRC (self-report) supplements, 

residents screening family history of 

1998, ≥ 50 CRC 

years 

N = 954 

Fair 

General Health Status 

Berkowitz et 

al., 200855 

Crosssectional, 

retrospective 

, national 

HINTS 

(2003) 

respondents 

65-89 years 

old 

N = 1,148 

Fair 

Assess 

beliefs and 

perceptions 

of risk about 

CRC and 

gaps in 

knowledge 

about 

screening in 

adults ages 

65-89 years 

FOBT (within 

past year) or, 

FS or 

colonoscopy 

in past 10 

years (selfreport) 

General health 

status 

(excellent, very 

good, good, 

fair, poor) 

Gender, race, 

income, 

education, 

marital status, 

family history of 

CRC, health 

status, regular 

source of care, 

annual MD 

visits, 

knowledge 

about CRC and 

testing, beliefs 

about CRC, 

perceived risk 

No statistically 

significant 

difference based 

on perceived 

health status 

People who perceived 

their health to be 

excellent or very good 

were no more or less 

likely to be up-to-date 

with CRC screening 

than those who are in 

fair or poor health 

(P = 0.11) 

80 
Table 19. Studies of the association of personal health/risk factors with CRC screening (continued) 

Author, 

Year 

Study 

Design 

Population 

Setting 

Sample 

Size 

Primary 

Outcome of 

Interest for Predictors 

Potential 

Confounders 

Variables 

Associated 

with CRC 

Quality Study Aims Review Examined Considered Screening* Results (95% CI) 

Risk Factors (Obesity, smoking, physical inactivity) 

Heo et al., 

2004145 Estimate 

the 

FOBT in past 

year or FS in 

5 body mass 

index-defined 

Age, education, 

race, income, 

↑ Obesity for FS 

screening 

Body mass index was 

not associated with 

association past 5 years categories: general health obtaining an FOBT 

Cross- between (self-report) Normal status, smoking, No differences (AORs ranged from 

sectional/ body mass weight = 18.5­ employment, by obesity for 0.90-0.98) 

retrospec­ index and < 25 health insurance FOBT 

tive, national CRC Overweight = 2 Compared with normal 

screening 5- < 30 weight adults, those 

BRFSS, Obesity Class who were overweight 

2001, ≥ 50 I = 30 - < 35 (AOR, 1.15; 95% CI, 

years Obesity Class 

II = 35 - < 40 

1.02-1.31); in the 

obesity class I (1.21, 

N = 84,284 Obesity Class 95% CI, 1.09-1.35), II 

III = ≥ 40 (1.17; 95% CI, 1.04­

Fair 1.44); and III (1.27; 

95% CI, 1.05-1.58) 

were more likely to 

have obtained a 

screening FS within the 

past 5 years (P < 0.05) 

Rosen and Evaluate FOBT in past Normal weight Age, gender, ↓ Morbidly Morbidly obese 

Schneider, 

2004126 whether 

association 

year or 

endoscopy in 

(body mass 

index = 18.5­

ethnicity, 

education, 

obese females 

for FOBT or 

females were less 

likely than females with 

exists past 10 years 24.9); marital status, endoscopy a normal body mass 

Cross- between (self-report) Overweight income, census index to receive CRC 

sectional, body mass (25.0-29.9); region, self- screening (AOR, -5.6; 

retrospec­ index and Obese (30.0- reported health 95% CI, -2.6 to -8.5). 

tive, national CRC 34.9); Morbidly status, smoking There were no obesityBRFSS, 

screening obese (≥ 35) status, time 

since last 

related disparities in 

screening rates for 

1999, 51-80 checkup, males 

years insurance status 

N = 52,886 

Fair 

81 
Table 19. Studies of the association of personal health/risk factors with CRC screening (continued) 

Author, Year 

Study 

Design 

Population Primary 

Setting Outcome of Potential Variables 

Sample Size Interest for Predictors Confounders Associated with 

Quality Study Aims Review Examined Considered CRC Screening* Results (95% CI) 

Ferrante et Examine FOBT within Obesity (body Age, gender, ↓ Obese for any Obese patients had 25% 

al., 2006166 whether past year, FS mass index ≥ 30 number of CRC test decreased odds of being 

obesity is or double- kg/m2

) compared comorbidities, screened for CRC 

Cross- associated contrast with non-obese number of visits compared with nonobese 

sections, with lower barium enema in past 2 years, patients (AOR, 0.75; 

retrospec- rates of CRC in past 5 number of years 95% CI, 0.62-0.91; 

tive, 22 PCP screening years, attending P = 0.004) 

practices colonoscopy practice 

in past 10 

Chart reviews years (claims) 

in 22 PCP 

practices in 

New Jersey 

and 

Pennsylvania, 

2003-2004, 

≥ 50 

N = 1,297 

Fair 

Maleis et al., 

2006132 

Crosssectional/ 

retrospective, 

state 

Maryland 

Cancer 

Survey, 2002, 

≥ 50 years 

N = 3,436 

Fair 

Determine 

whether 

overweight or 

obese adults 

ages 50 

years or 

older are upto-date with 

CRC 

screening 

FOBT within 

past year, FS 

in past 5 years 

or 

colonoscopy 

in past 10 

years (selfreport) 

Normal or underweight (body 

mass index 

< 25); overweight 

(body mass 

index 25-29.9); 

obese (body 

mass index ≥ 30) 

Age, race, 

gender, marital 

status, 

education, 

employment, 

geographic area, 

health insurance 

status, having 

had a physical 

examination in 

past 2 years, 

CRC screening 

recommenddations 

No statistically 

significant 

difference based 

on weight 

Overweight people had 

similar odds of being upto-date with CRC 

screening as normal or 

underweight people 

(AOR, 1.05; 95% CI, 

0.83-1.33) 

Obese people had 

slightly lower, though 

statistically insignificant, 

odds of screening (AOR, 

0.84; 95% CI, 0.65-1.09) 

82 
Table 19. Studies of the association of personal health/risk factors with CRC screening (continued) 

Author, 

Year 

Study 

Design 

Population 

Setting 

Sample 

Size 

Primary 

Outcome of 

Interest for Predictors 

Potential 

Confounders 

Variables 

Associated 

with CRC 

Quality Study Aims Review Examined Considered Screening* Results (95% CI) 

Thorpe et 

al., 2005114 Examine 

characteristi 

FOBT within 

past year, FS 

Current 

smoking 

Age, race, family 

and 

↓ Current 

smoker 

Current smokers (AOR, 

0.62; 95% CI, 0.49­

cs of people in past 5 (nonsmoker or neighborhood 0.78) and residents who 

Cross- undergoing years, or current); income, ↓ physically reported being 

sectional/ screening colonoscopy physical activity ethnicity, inactive physically inactive 

retrospec­ within in past 10 (some activity gender, personal (AOR, 0.74; 95% CI, 

tive, local guidelines years (self­ or none) risk factors 0.63-0.88) were less 

report) (current likely to be current on 

Community smoking, CRC screening 

Health physical 

Survey, New inactivity), (P NR) 

York City access to care, 

residents, insurance, 

2003, ≥ 50 regular source of 

years care 

N = 3,606 

Fair 

AOR, adjusted odds ratio; BRFSS, Behavioral Risk Factor Surveillance System; CI, confidence interval; CRC, colorectal cancer; FOBT, fecal 

occult blood test; FS, flexible sigmoidoscopy; HINTS, Health Information National Trends Survey; N, number; P, probability; PCP, primary care 

physician; PSA, prostate-specific antigen; RDD, random digital dialing. 

* Arrow symbols (↓or ↑) are provided as a quick reference point of overall findings and represent the association reported between each variable 

and CRC screening. 

All but two studies included respondents 50 years of age or older in their samples; persons 

65-89 years were in one study,55 and persons 51-80 years in the other.126 

Studies defined outcomes of CRC screening differently, as follows: 

•	 Two studies considered a respondent to be screened if they reported an FOBT in the past 

year or endoscopy (i.e., FS or colonoscopy) in the past 5 years;145,157 

•	 Two studies defined the outcome of interest as FOBT in the past year or endoscopy in the 

past 10 years;55,126 

•	 Four studies defined screening as FOBT in past year, FS or double-contrast barium 

enema in past 5 years, or colonoscopy in past 10 years;108,114,132,166 

•	 One study defined it as FOBT in past year, FS or double-contrast barium enema in the 

past 5 years, or colonoscopy in the past 10 years.137 

Overview of results. We have divided our overview of results into two groups. Presented 

first are health factors such as having a family history of CRC, participating in other healthy 

practices like being screened for other cancers, and general health status in relation to screening. 

This is followed by information on risk factors such as obesity, smoking, and sedentary lifestyle. 

With respect to family history of CRC, findings are generally consistent with those from the 

three overview studies:21,46,151 having a family history of CRC was associated with a higher 

likelihood of obtaining CRC screening. One study using regional, self-reported findings yielded 

83 
data showing that that those with a family history of CRC were more likely than others to be upto-date with CRC screening in general (AOR, 1.74) and for colonoscopy (AOR, 2.61).108 

Several other studies reported similar findings supporting a strong association between 

family history and screening for CRC.2,55,122,134,137,142,158 Only one study reported that subjects 

with a family history of CRC were not more likely to be screened for CRC (AOR, 0.85; 

P = 0.43).55 Five additional studies reported an association between family CRC history and 

screening rates in their final multivariate analysis.2,42,107,122,134,158 

Two studies showed that, among both males and females, obtaining regular screening for 

other cancers was associated with CRC screening; this is consistent with the three overview 

studies.21,46,151 The 1998 study that examined screening among males and females found that 

other cancer screening, including mammogram or prostate specific antigen (PSA) testing, was 

significantly associated with CRC screening (AOR, 4.40; P < 0.001).137 Another, which used 

2001 BRFSS data, reported that subjects up to date for mammograms and Pap smears were more 

likely than those no up to date to be screened for CRC (AOR 2.42 for mammograms and AOR 

1.70 for Pap smears; P < 0.01 for both).157 Other studies included in this report support the 

positive association of other cancer screening behavior with CRC screening.42,108,122-123,133­

134,156,158 

With respect to other healthy behaviors, one study that reported an association between 

vitamin supplement use and CRC screening (AOR, 1.87).137 

For general health status, a few studies examined the association between perceived health 

status and CRC screening, as did the three overview studies,21,46,151 but overall findings are 

inconsistent. The study based on the 2003 HINTS national survey showed no association 

between perceived general health and CRC screening (P = 0.11).55 Another study reported that 

females who perceived their health as good were less likely to adhere to CRC screening than 

those perceiving their health to be fair or poor (AOR, 0.79; P < 0.01).157 Another study presented 

related factors, including a number of chronic illnesses and Charlson scores (i.e., a weighted 

index of 19 selected categories of disease found to be associated with mortality and other 

important health outcomes, in which a higher scores equates with worse health) obtained through 

medical record review. This group reported that patients with more illnesses were more likely to 

be screened (AOR, 1.12; P < 0.0001) but that those with higher Charlson scores were less likely 

to be screened (AOR, 0.84; P = 0.0001).158 

Six other studies not presented in this section but that included perceived health in their final 

multivariate analysis also found that those with more positive perceptions of their health (i.e., 

excellent, very good, good) were less likely to report current CRC screening than those with 

lower or less positive perceived health,1,107,111,120,134,157 another study reported the opposite results 

such that those with perceived good health were more likely to be screened.163 Another study 

found no association between perceived health and screening behavior.2 

In terms of obesity, four studies reflected inconsistencies about the association of weight with 

CRC screening.126,132,145,166 One study using data from 84,284 subjects from the 2001 BRFSS 

classified patients into five body mass index categories and found that no association between 

body mass index and FOBT completion.145 For this study, the authors did find that overweight or 

obese males were more likely to have obtained FS within the past year compared to females 

(P < 0.05).145 Another study based on 1999 BRFSS data found only an association between CRC 

screening for morbidly obese females and no differences for any other body mass index category 

in comparisons with respondents of normal weight (AOR, -5.6).126 Another study used data from 

the Maryland Cancer Survey and found that overweight and obese people had odds of being upto-date with CRC screening similar to those for people of normal weight (AOR, 1.05 and AOR, 

0.84, respectively).132 In the fourth study, obese patients in primary care provider practices were 

84 
less likely than normal-weight patients to be screened for CRC (AOR, 0.75; P = 0.004).166 

Another study (not included in summary table) explored the relationship between BMI and CRC 

screening in American Indian and Alaskan Native men and found no association between these 

two variables in a nationally representative survey conducted in 2004-2005.131 Yet another study 

found that persons who were categorized as overweight were slightly more likely to have 

received an endoscopy and/or FOBT (RR, 1.2 and 1.1, respectively, P < 0.05).111 

With respect to smoking and sedentary lifestyle (i.e., physical inactivity), one study reported 

findings from a community survey of New York city residents;114 current smokers (AOR, 0.62) 

and residents who reported being physically inactive (AOR, 0.74) were less likely (than various 

comparison groups) to be current on CRC screening.114 Similarly, another study reported that 

current smokers were less likely to be screened by endoscopy (AOR, 0.13; P = 0.009).106 Both 

studies support the findings from the three overview studies, which found that current smokers 

were less likely to be screened for CRC than those who had never or were former 

smokers.21,46,151 

Four other studies (omitted in Table 19 because their analysis focused on other patient 

characteristics and CRC screening) supported the three overview studies in reporting that current 

smokers were less likely than former or never smokers to report being screened.115,122,126,157 One 

study reported no difference in smoking status and CRC screening.116 

Psychosocial factors. Study characteristics. Another topic addressed by several studies is the 

extent to which psychosocial factors (i.e., knowledge, attitudes, beliefs, or perceptions about 

cancer and/or screening) may predict CRC screening behavior. As previously noted, two of the 

overview studies21,46 presented findings related to some psychosocial factors; both found that 

knowledge of screening tests were predictors for screening. 

Table 20 presents summary information for the five studies involving the association 

between these factors and CRC screening; all involved self-reported responses from survey data 

influencing screening.55,106,133-134,144 Two national studies were based on HINTS data collected 

from the fall 2002 through spring 2003.55,133 Another study collected data from a sample residing 

in a five-county region of the Midwest;134 another study collected data locally from patients 

using three neighborhood clinics;106 while the remaining study collected data from Japanese 

Americans residing in the Greater New York region.144The ages of respondents in the five 

studies differed: two studies collected data from those 50 years or older,133,144 another study used 

data from those 51 years or older;106 a third presented findings on those 65 to 80 years of age;55 

and the remaining study presented findings specific to those ages 50-79 years.134 

Three different definitions of screening were used to determine whether respondents were 

up-to-date: two studies used the definition that an FOBT had been obtained within the past year 

and FS or colonoscopy within the past 10 years;55,133 two studies defined being screened as 

reporting an FOBT in the past year, FS in the past 5 years, or colonoscopy in the past 10 

years;134,144 and one focused on endoscopy screening (i.e., FS in the past 5 years or colonoscopy 

in the past 10 years).106 

Overview of results. Various authors have tended to define psychosocial factors somewhat 

differently; we divide the discussion of these factors into the four categories of knowledge, 

attitudes, perceptions, and beliefs. Table 21 summarizes the items included in each survey 

analysis of the studies in this section. In terms of knowledge or awareness of CRC or the 

available tests, two studies presented findings about whether respondents reported: 

(1) understanding the appropriate intervals of testing,133 (2) being aware of the types or numbers 

of tests available,55 and (3) knowing the expense of each test.133 

85 
Table 20. Studies of the association between psychosocial factors and CRC screening 

Author, Year 

Primary Outcome 

of Interest for 

Study 

Design 

Population 

Setting 

Sample Size 

Quality Study Aims 

Review 

(i.e., screening or 

followup after 

abnormal FOBT; 

completion rates or 

discussions) 

Predictors 

Examined 

Potential 

Confounders/ 

Modifiers 

Reported 

Variables 

Associated 

with CRC 

Screening Results (95% CI) 

McQueen et 

al., 2006133 Examine 

correlates of 

Any test (endoscopy 

in the last 10 years 

Perceived risk 

to CRC; beliefs 

Demographics 

, access, 

↑ Understood 

appropriate 

Males and females 

were more likely to 

test use by or FOBT in the last about testing health status, time intervals be screened if they 

Cross- gender year) (self-report) (i.e., fear of health for tests understood the 

sectional, finding cancer; behaviors appropriate time 

retrospective, getting tests is ↑ Fear of intervals for FOBT 

national too expensive) finding (AOR, 5.42; 95% 

or knowledge cancer with CI, 2.52-11.66 for 

HINTS, 2002­ of testing (i.e., test; males and AOR, 

2003, ≥ 50 time intervals of perceived 5.25; 95% CI, 

years tests) risk to CRC 

for females 

3.23-8.52 for 

female) and 

N = 2,686 endoscopy (AOR, 

↓ Did not 4.69; 95% CI, 

Good know if tests 2.55-8.65 and 

are too AOR, 3.18; 95% 

expensive for CI, 2.26-4.47, 

endoscopy respectively) 

↓ Did not Females were 

know costs more likely to be 

or believed screened if they 

too believed they were 

expensive for more likely than 

FOBT others to be 

diagnosed with 

CRC (AOR, 2.53; 

95% CI, 1.43-4.46 

for endoscopy); if 

they believed CRC 

testing leads to 

early detection 

(AOR, 3.03; 95% 

CI, 1.03-8.93 for 

FOBT); or if they 

had a fear of 

finding cancer 

(AOR, 1.78; 95% 

CI, 1.18-2.68) 

86 
Table 20. Studies of the association between psychosocial factors and CRC screening (continued) 

Author, Year 

Primary Outcome 

of Interest for 

Study 

Design 

Population 

Setting 

Sample Size 

Quality Study Aims 

Review 

(i.e., screening or 

followup after 

abnormal FOBT; 

completion rates or 

discussions) 

Predictors 

Examined 

Potential 

Confounders/ 

Modifiers 

Reported 

Variables 

Associated 

with CRC 

Screening Results (95% CI) 

McQueen et 

al., 2006133 

(continued) 

 Males and females 

were less likely to 

be screened if they 

didn’t know if the 

tests were too 

expensive (0.43; 

95% CI, 0.24-0.78 

and 0.46; 95% CI, 

0.30-0.71 for 

endoscopy, 

respectively) 

Females were also 

less likely to be 

screened with 

FOBT if they 

believed it was too 

expensive (AOR, 

0.55; 95% CI, 

0.32-0.93) or didn’t 

know the costs 

(AOR, 0.46; 95% 

CI, 0.27-0.79) 

All P values < 0.05 

Berkowitz et 

al., 200855 Assess 

beliefs and 

FOBT (within past 

year) or, FS or 

Beliefs about 

testing (i.e., 

Gender, race, 

income, 

↓ Beliefs of 

lack of ease 

Respondents who 

believed that it is 

perceptions colonoscopy in past arranging to education, of testing and not easy to 

Cross- of risk about 10 years be checked is marital status, tests being arrange to be 

sectional, CRC and (self-report) easy; fear of family history of too tested (AOR, 0.47; 

retrospective, gaps in finding cancer; CRC, health expensive; 95% CI, 0.25-0.91) 

national knowledge getting status, regular lack of or that the tests 

about checked source of care, knowledge of are too expensive 

HINTS, 2003, screening in increased annual MD available (AOR, of 

65-89 years adults ages odds of visits, tests disagreeing with 

65-89 years getting knowledge test being too 

N = 1,148 cancer; about CRC and expensive = 1.25; 

getting tests is testing, beliefs 95% CI, 0.80­

Fair too expensive) about CRC, 1.97); or had a 

or knowledge perceived risk lack of knowledge 

of testing (i.e., about the number 

age of likely of available tests 

onset; number (AOR, 0.28; 95% 

of available CI, 0.19-0.42) 

tests) were less likely to 

report being 

screened 

P values at 0.03 or 

better 

87 
Table 20. Studies of the association between psychosocial factors and CRC screening (continued) 

Primary Outcome 

Author, Year of Interest for 

Study Review 

Design (i.e., screening or 

Population followup after Potential Variables 

Setting abnormal FOBT; Confounders/ Associated 

Sample Size completion rates or Predictors Modifiers with CRC 

Quality Study Aims discussions) Examined Reported Screening Results (95% CI) 

Honda and To develop FOBT in past year; Emotional Age, income, ↑ Emotional Emotional friend 

Singer, and test a FS in past 5 years; or family and education, family support had direct 

2006144 model to colonoscopy in past friend support acculturation, support impacts on 

explain 10 years (family’s and marital status, indirectly adherence 

Cross- factors (self-report) friends’ and insurance related to (γ = 0.15); 

sectional, related to concern for adherence emotional family 

retrospective, CRC and support was 

regional screening understanding ↑ Emotional indirectly related to 

adherence of you, friend adherence via 

Survey among reliance on support increased 

administered Japanese family/friends) directly subjective norms 

by phone in Americans related to among family and 

the Greater adherence friends (γ = 0.12). 

NY region 

(NY, NJ, CT), 

Japanese 

Americans 50 

years or older 

N = 341 

Fair 

Matthews et Identify FOBT within past 

al., 2007134 indicators of year, FS in past 5 

up-to-date years, or 

Cross- CRC colonoscopy in past 

sectional, screening 10 years (self-report) 

retrospective, 

regional 

Survey 

administered 

to 5-county 

region in 

Midwest, 

2005, 50-79 

years 

N = 1,033 

Fair 

Perceived Gender, age, ↑ Belief that Respondents were 

beliefs (i.e., race, education tests are more likely to be 

CRC tests are safe; screened if they 

safe; if irresponsible believed the tests 

healthy, no not to test; are safe (AOR, 

need to test; positive 1.39; 95% CI, 

irresponsible attitude 1.09-1.78); that it’s 

not to test); or about cancer irresponsible not to 

attitudes (i.e., screening get tested (AOR, 

anxiety about 2.16; 95% CI, 

tests; positive ↓ Anxiety 1.67-2.78); or had 

attitude about tests; a positive attitude 

toward and belief about screening in 

screening in that if general (AOR, 

general) healthy, no 2.35; 95% CI, 

need to test 1.76-3.13) 

Respondents were 

less likely to be 

screened if they 

had anxiety about 

the tests (AOR, 

0.50; 95% CI, 

0.49-0.64) or 

believed that if 

they are healthy, 

they don’t need to 

be tested (AOR, 

88 
Table 20. Studies of the association between psychosocial factors and CRC screening (continued) 

Author, Year 

Primary Outcome 

of Interest for 

Study 

Design 

Population 

Setting 

Sample Size 

Quality Study Aims 

Review 

(i.e., screening or 

followup after 

abnormal FOBT; 

completion rates or 

discussions) 

Predictors 

Examined 

Potential 

Confounders/ 

Modifiers 

Reported 

Variables 

Associated 

with CRC 

Screening Results (95% CI) 

Matthews et 

al., 2007134 0.58; 95% CI, 

0.42-0.79) 

(continued) 

P values are all 

0.05 or better 

Zimmerman 

et al., 2006106 Identify 

determinants 

FS in past 5 years, 

colonoscopy in past 

Barriers to 

endoscopy 

Age, race ↓ Perceived 

barriers for 

People who 

reported barriers to 

of patient­ 10 years, or both (perceived endoscopy endoscopy were 

Cross- reported (FOBT not included) inconvenience less likely than 

sectional, receipt of (self-report) or trouble; those who did not 

retrospective, CRC unpleasantness to be screened by 

local screening of test) endoscopy (AOR, 

0.33; 95% CI, 

Survey 0.18-0.60; 

administered P < 0.0001) 

in 3 clinics, 

2003, > 50 Perceived social 

years support for CRC 

screening was not 

N = 325 associated with 

screening 

Fair 

AOR, adjusted odds ratio; CI, confidence interval; CRC, colorectal cancer; FOBT, fecal occult blood test; HINTS, Health Information National 

Trends Survey; MD, medical doctor; γ, gamma. 

* Arrow symbols (↓or ↑) are provided as a quick reference point of overall findings and represent the association reported between each variable 

and CRC screening. 

Table 21. Types of factors and descriptions of variables used in selected studies to examine the influence of 

psychosocial factors on CRC screening 

Types of 

Psychosocial 

Factors Used in 

Selected Studies Knowledge Attitudes Perceptions Beliefs 

Description of 

Variables Used 

• Understood time 

intervals for 

• Positive 

attitude 

• Perceived 

barriers to 

• Believes: 

• Tests are safe134 

taking test133 

• Does not know if 

test is expensive 

or what the cost 

is133 

• Knows tests that 

are available55 

toward 

cancer 

screening134 

• Has anxiety 

about test134 

• Fearful of 

finding 

cancer133 

screening106 

• Perceived social 

support to get 

testing106,144 

• Perceived 

risk/susceptibility 

to CRC133,144 

• Irresponsible not to 

test134 

• If healthy, no need to be 

tested134 

• Tests lead to early 

detection133 

• Not easy to arrange to 

be tested55 

CRC, colorectal cancer. 

One national study using the 2002-2003 HINTS reported that both males and females were 

statistically more likely to be screened if they understood the appropriate time intervals of both 

the FOBT and endoscopy (AOR, range 4.69-5.42 for males and 3.18 and 5.25 for females; all P 

values < 0.05).133 The same study found that males and females who did not know whether tests 

were “too expensive” (for them) were less likely than those who did know to receive an 

89 
endoscopy (AOR, 0.43 and 0.46, respectively; P < 0.05); this same finding was also reported for 

females and FOBT testing (AOR, 0.55; P < 0.05).133 In another study, respondents 65 years of 

age or older who lacked knowledge about the number of tests that were recommended for their 

age group were less likely to be screened that knew about the recommended guidelines for 

testing frequency (AOR, 0.28).55 

With regard to attitudes about testing or CRC, one study reported findings about overall 

attitudes toward screening and anxieties about tests from a regional survey of residents in the 

Midwest.134 If respondents had a positive attitude toward screening in general, they were more 

likely to report being screened (AOR, 2.35); if they had anxiety about tests in general, they were 

less likely to be screened (AOR, 0.58).134 Being fearful of finding cancer was positively 

associated with CRC screening among women in one study (AOR, 1.78).133 

Three studies reported findings specific to perceived barriers to screening and perceived 

social support for screening, as well as perceived risk to being diagnosed with cancer.106,133,144 

Perceived barriers to screening by endoscopy (e.g., inconvenience and unpleasant aspects of 

screening are perceived to be a problem) were associated with not being screened for CRC 

(AOR, 0.33; P < 0.0001) in one study. Another study highlighted in another section of this 

chapter also reported findings that support a relationship between perceived barriers to screening 

and adherence.142 Perceived social support to be screened was not associated with screening in 

one study,106 but was both indirectly (through perceived emotional support from family) and 

directly (through perceived emotional support from friends) related to adherence to screening in 

the one included study that tested a structural equation model to examine factors influencing 

screening.144 Perceived risk to being diagnosed with cancer was positively associated with being 

screened for females (AOR, 2.53).133 Two other studies not presented in this section found that 

perceived risk to being diagnosed with CRC was associated with screening.108,130 

Three studies included analyses of beliefs that may be associated with CRC screening. 

Positive associations with CRC screening were found with the following beliefs: that the tests are 

safe (AOR, 1.39);134 that it is irresponsible not to be tested (AOR, 2.16);134 and, for females, that 

tests lead to early detection (AOR, 3.03).133 Those who believed that, if they are healthy, they do 

not need to be tested were less likely to report being screened (AOR, 0.58)134 as were those who 

thought that arranging for testing would not be easy (AOR, 0.47).55 

Another study not presented in this section (because psychosocial factors were not a specific 

aim of their research) reported no association between belief that testing detects cancer early and 

screening rates.108 

Patient Factors: Followup after Positive FOBT 

Study characteristics. We identified two studies, both rated as fair quality, that assessed 

factors that may be related to followup after an abnormal FOBT result (Table 22).88,168 Both 

studies were conducted using claims data from one Veterans Administration (VA) Hospital; one 

focused on patients 70 years of age or older168 and the other on patients 50 or older.88 The 

outcome measure of interest to both was whether a patient completed a colonoscopy or doublecontrast barium enema168 or a full colon evaluation (defined as colonoscopy or double-contrast 

barium enema with FS)88 within 12 months of receiving the FOBT results. 

90 
Table 22. Studies of factors associated with followup after abnormal CRC screening results are received 

Author, Year 

Study 

Design 

Population 

Setting 

Sample Size 

Quality

Garman et 

al., 2006168 

Crosssectional/ 

retrospective, 

local 

1 VA hospital, 

patients 70 

years or older 

N = 266 

Fair 

 Study Aims 

Examine 

comorbid 

disease and 

performance 

of complete 

full colon 

evaluation 

after positive 

FOBT 

Primary 

Outcome of 

Interest for 

Review 

(i.e., screening 

or followup 

after abnormal 

FOBT; Variables 

completion 

rates or 

discussions) 

Predictors 

Examined 

Potential 

Confounders/ 

Considered 

Associated 

with CRC 

Screeninga Results (95% CI) 

Completion of Comorbidity Age No association Patients receiving 

colonoscopy, or (measured with Charlson followup who had higher 

double-contrast by Charlson score Charlson scores did not 

barium enema Comorbidity differ significantly from 

after positive Score) those who had lower 

FOBT (claims) scores (P = 0.38) 

Fisher et al., 

200688 

Crosssectional, 

retrospective, 

local 

1 VA hospital, 

50 years or 

older 

N = 538 

Fair 

Explore 

factors 

associated 

with 

undergoing a 

full colon 

evaluation 

after a 

positive 

FOBT 

Completion of a 

full colon 

evaluation (with 

a colonoscopy 

or doublecontrast barium 

enema plus FS) 

within 12 months 

of receiving 

positive FOBT 

(claims) 

Race Race, age, No association Blacks were as likely to 

(white, marital status, with race receive full colon 

Black, primary care examination as whites 

missing) clinic where (AOR, 1.14; 95% CI, 

FOBT 0.57-1.75) 

obtained 

AOR, adjusted odds ratio; CI, confidence interval; CRC, colorectal cancer; FOBT, fecal occult blood test; FS, flexible sigmoidoscopy; N, 

number; OR, odds ratio; VA, Veterans Administration. 

Overview of results. Each study examined different predictors for receipt of a follow-up 

test. One explored the association of comorbidity (measured through Charlson scores)168 and the 

investigated the differences in followup for white and Blacks.88 The study focusing on 

comorbidities found that patients who had higher Charlson scores (i.e., more comorbidities) were 

no more likely than those with low scores to receive followup after a positive FOBT.168 Followup rates after a positive FOBT were not associated with race; Blacks were as likely to receive a 

full colon evaluation as whites (AOR, 1.14).88 

Physician Factors Associated with CRC Screening 

This part of KQ 2 focuses on physician factors associated with CRC screening, CRC 

screening discussions, or the quality of CRC screening. Although we found many studies that 

examined the association of patient characteristics and CRC screening, we found only one study 

91 
that examined physician characteristics,127 one study that examined “patient-physician 

connectedness,”152 and 12 studies that examined physician recommendation of CRC screening. 

Of these 12 studies, 7 were national studies from two databases (NHIS and HINTS)21,46,55­

57,111,159 and 5 were regional studies from four different states or areas.107,142,148,153 

Physician characteristics. Study characteristics. This cross-sectional study, which we rated 

fair quality, used data from the 2000-2001 Community Tracking Study (CTS) Physician Survey 

(response rate 59 percent), a nationally representative telephone survey of nonfederal physicians 

in 60 randomly selected metropolitan statistical areas (Table 23).127 Among other items, the CTS 

asked physicians about their age, years in practice, specialty, board certification, and site of 

medical school graduation (US/Canada versus other). The investigators assessed information on 

CRC screening and patient care visits for Medicare beneficiaries ages 65 years and older from 

Medicare claims data. The investigators linked the databases by physician ID numbers, allowing 

them to identify 3,660 primary care physicians who cared for 24,581 Medicare beneficiaries in 

the database. They could then generate 1-year (2001) CRC screening rates for physicians with 

similar characteristics. 

Table 23. Studies of the association between physician characteristics and CRC screening 

Author, Year, Study 

Design, Population, 

Setting, Sample size, 

Quality 

Pham et al., 2005127 

Primary 

Outcomes of 

Interest for 

Review 

1-year rates of 

Predictors 

Examined 

Physician and 

Potential 

Confounders 

Considered 

Patient coVariables 

Associated 

with CRC 

Screening* 

↑ Family 

Results (95% CI) 

Association between 

colonoscopy or practice morbidity, physicians CRC screening and 

Cross-sectional study, FS, excluded characteristics, individual income physician specialty 

retrospective, National FOBT including use of and other ↑ Board (patients cared for by 

2000-2001 (self-report and computerized demographic certified family physicians 9.9% 

claims) physician and education vs. patients cared for by 

Nationally representative reminders, size factors; doctor­ ↑ US Medical general internists 7.8%, 

physician survey and and type of the patient school P < 0.001); board 

Medicare claims data, practice. interaction graduate certification (board 

2000-2001 factors; certified 9.5% vs. not 

managed care No other board certified 6.5%, 

N = practice factors; associations P < 0.05); and site of 

3,660 physicians 24,581 system factors. identified medical school 

patients (≥ 50 years) graduation (US or 

Canada 9.3% vs. non-US 

Fair or Canada 7.7%, 

P < 0.05). 

CI, confidence intervals; CRC, colorectal cancer; FOBT, fecal occult blood test; FS, flexible sigmoidoscopy; N, number; P, probability; US, 

United States 

* Arrow symbols (↓or ↑) are provided as a quick reference point of overall findings and represent the association reported 

between each variable and CRC screening. 

Overview of results. CRC screening rates did not differ between patients with male versus 

female physicians; neither did they differ among physicians who had been in practice for 0-10 

years versus 11-20 years versus > 20 years. Patients cared for by family physicians had 

somewhat higher 1-year screening rates than those cared for by general internists (9.5 percent 

versus 7.8 percent, P < 0.001); patients cared for by board certified physicians had higher 

screening rates than those cared for by non-board certified physicians (9.5 percent versus 6.5 

percent, P < 0.05). Patients cared for by physicians who graduated from US or Canadian medical 

schools had higher screening rates than those cared for by physicians who graduated from other 

medical schools (9.3 percent versus 7.7 percent, P < 0.05). Another study (highlighted under 

patient level factors) explored the relationship between race and screening among a nationally 

representative sample of Medicare beneficiaries and found that, controlling for other factors, 

92 
patients whose usual care physician was a primary care generalist rather than another type of 

specialist had significantly higher odds of CRC screening (AOR, 1.31; 95% CI, 1.12-1.53).129 

Physician-Patient connectedness. Study characteristics. A retrospective cohort study, 

which we rated good quality, examined the association between CRC screening and patientphysician connectedness (Table 24).152 Although this variable could be seen as either a system 

variable or a patient-physician interaction variable, we have elected to review it under physician 

characteristics because the study was conducted in a single large academic practice network with 

large variation among physicians (e.g., specialty, number of years in practice, etc.), indicating 

that the variable at least partially indicated physician practice style. It was conducted in the 

Massachusetts General Hospital adult primary care network (181 primary care physicians 

working in four community health centers and nine hospital-affiliated practices). Using 

electronic billing records, the investigators identified all patients with at least one visit to one of 

these practices between 2003 and 2005. Using a validated algorithm, the investigators further 

divided these patients into three groups: practice-connected (i.e., patient was considered a regular 

user of the practice but had seen a variety of physicians within the practice), physician-connected 

(i.e., a patient of the practice as well as seen by the same physician for most visits), or 

unconnected (i.e., patient could not be assigned to either a practice or a physician). Using 

electronic billing and laboratory data, the investigators calculated, among other indicators, CRC 

screening rates (colonoscopy within 10 years, FS within 5 years, or FOBT within one year) for 

physician-connected patients (n = 31,215) versus practice-connected patients (n = 6,453), 

excluding unconnected patients (who were often either just entering or leaving the practice). 

Table 24. Studies of the association between physician or practice connectedness with CRC screening 

Independent Predictors of 

Author, Year, Study Design, Variables of CRC 

Population, Setting, Sample Primary Primary Potential screening 

size, Quality Outcomes Interest Confounders Identified Results 

Atlas et al., 2009152 

Retrospective cohort study, data 

collected, practice based 

Medical records review, 2003­

2005, patients ≥ 50 

N = 181 primary care physicians, 

n = 31,215 physician connected 

patients and 6,453 practice 

connected patients 

Good 

FOBT within 

past year, 

FS within 

past 5 

years, 

colonoscopy 

within past 

10 years 

(claims) 

Physician vs. 

practice 

connectedness, 

determined by 

a validated 

algorithm 

Patient and 

physician 

characteristics, 

characteristics 

of the patientphysician 

interaction, 

financial 

(insurance) 

characteristics, 

all controlled for 

in analysis. 

↑ Physician 

connectedness 

↑ Practice 

connectedness 

Adjusted CRC 

screening rates: 

Physician 

connected 

patients: 72.1% 

(95% CI, 70.5­

73.7) 

Practice 

connected 

patients: 58.0% 

(95% CI, 56.7­

59.4) 

P < 0.001 

CI, confidence interval; CRC, colorectal cancer; FOBT, fecal occult blood test; FS, flexible sigmoidoscopy; N, number; P, probability. 

* Arrow symbols (↓or ↑) are provided as a quick reference point of overall findings and represent the association reported 

between each variable and CRC screening. 

Overview of results. Physician-connected patients had higher CRC screening rates (adjusted 

percentage 77.1) than practice connected patients (adjusted percentage 69.5; P < 0.001). 

Physician recommendation. We found 12 studies that examined the association between 

CRC screening and physician recommendation of CRC screening. Seven are analyses from two 

large national databases: NHIS and Health Information National Trends Survey (HINTS).21,46,55­

57,111,159 The other five studies are regional studies.107,136,142,148,153 We discuss the seven national 

papers and then assess what additional insights come from the regional studies. Agreement of 

results among all these studies is high. 

93 
Study characteristics of national studies. As shown in Table 25, four of the seven national 

studies used the NHIS 2000 cancer control module;21,57,111,159 one used the NHIS 2005 cancer 

control module.46 Two studies analyzed the 2002-2003 HINTS database.55-56 We rated three 

studies as good quality21,46,56 and the remainder as fair. 

Table 25. National studies of association between physician recommendations and CRC screening 

Author, Year, 

Study Design, 

Population, 

Setting, Sample 

size, Quality 

Cairns et al., 200656 

Primary 

Outcome of 

Interest for 

review 

FOBT within the 

Independent 

Variables of 

Primary Interest 

Reasons for not 

Potential 

Confounders 

Age, insurance, 

Predictors of CRC 

screening 

Identified

↓ No physician 

 Results 

Among uninsured, 91% 

past year being screened whether there is a recommendation who received 

Cross-sectional, (self-report) usual provider, recommendation had 

national gender, received a test; those 

race/ethnicity, without a recommendation 

HINTS, 2002-2003, annual household were 98.5% less likely 

50-64 years income, (95% CI, 0.003-0.083) to 

employment, rural receive tests (P < 0.001). 

N = 1,253 vs. urban county, 

education 

Good 

Seeff et al., 200421 FOBT in past Physician Age, gender, race, ↓ No physician Of those 50-64 years, 

year; endoscopy recommendation ethnicity, recommendation 94.1% (95% CI, 93.3­

Cross-sectional, in past 10 years in past year as a education, marital 94.9%) who were not 

retrospective, (self-report) reason for not status, insurance current with testing had 

national having had a status, income, not been recommended by 

CRC test usual source of physician to get a FOBT; 

NHIS, 2000, ≥ 50 care, MD 92.8% (95% CI, 91.9­

visits/year, 93.7%) had not been 

N = 14,874 personal/risk recommended to get an 

factors endoscopy 

Good 

Of those ≥ 65, 95.9% 

(95% CI, 95.1-96.6%) had 

not received a physician 

recommendation for FOBT 

and had not been tested; 

95.2% (95% CI, 94.4­

96.1%) had not received a 

recommendation for an 

endoscopy 

94 
Table 25. National studies of association between physician recommendations and CRC screening 

(continued) 

Author, Year, 

Study Design, Primary 

Population, Outcome of Independent Predictors of CRC 

Setting, Sample Interest for Variables of Potential screening 

size, Quality review Primary Interest Confounders Identified Results 

Shapiro et al., FOBT in past Reasons for not Age, gender, race, ↓ No physician Of those who never had 

200846 year; endoscopy having a FOBT ethnicity, recommendation tests, lack of physician 

in past 10 years or endoscopy, by education, marital recommendation given as 

Cross-sectional, (self-report) colorectal cancer status, insurance reason for not having a 

retrospective, testing history, status, income, FOBT: 96.3% of those 

national NHIS 2005 usual source of who never had either test 

care, MD (95% CI, 95.6-96.9%); 

NHIS, 2005, ≥ 50 visits/year, 95.4% (95% CI, 94.7-96.0) 

personal/risk for those who had test but 

N = 13,269 factors not in recommended time. 

Good As a reason for no 

endoscopy; 89.7% of 

those who never had 

either test (95% CI, 88.5­

90.7%); 87.9% (95% CI, 

88.5-90.7%) of those who 

had test but not in 

recommended time 

Berkowitz et al., 

200855 FOBT (within 

past year) or, FS 

Physician 

recommendation 

Gender, race, 

income, education, 

↓ No physician 

recommendation 

Reasons for not being 

screened: 

or colonoscopy reported marital status, No recommendation 

Cross-sectional, in past 10 years family history of received for 65-74 year 

retrospective, (self-report) CRC, health olds: FOBT: 87.5% (95% 

national status, regular CI, 76.7–93.7%) 

source of care, FS/colonoscopy: 79.1% 

HINTS, 2002-2003; annual MD visits, (95% CI, 69.3-86.4%) 

65-89 years knowledge about 

CRC and testing, For those 75-89 years: 

N = 1,148 (583 not beliefs about CRC, FOBT: 84.4% (95% CI, 

up-to-date with perceived risk 70.6-92.3%); 

screening) FS/colonoscopy: 75.9% 

(95% CI, 64.1-86.2%) 

Fair 

Coughlin et al., 

2005159 Persons with no 

recent CRC test 

Physician 

recommendation 

Age, gender, race, 

ethnicity, marital 

↓ No physician 

recommendation 

Reasons for not being 

screened: 

as a reason for status, education, Physician didn’t 

Cross-sectional, not being tested years in US, family recommend FOBT: 94.6% 

retrospective, history of CRC, (95% CI, 94.0-95.2); 

national general health endoscopy: 93.5% (95% 

status, income, CI, 92.8-94.2) 

NHIS, 2000, ≥ 50 insurance status 

N = 11,480 

Fair 

95 
Table 25. National studies of association between physician recommendations and CRC screening 

(continued) 

Author, Year, 

Study Design, 

Population, 

Setting, Sample 

size, Quality 

Primary 

Outcome of 

Interest for 

review 

Independent 

Variables of 

Primary Interest 

Potential 

Confounders 

Predictors of CRC 

screening 

Identified Results 

Klabunde et al., 

200557 No FOBT in past 

year nor 

Physician 

recommendation 

Age, gender, race, 

ethnicity, marital 

↓ No physician 

recommendation 

Among respondents who 

had not been tested for: 

endoscopy in status, education, FOBT: 21.6% (95% CI, 

Cross-sectional, past 10 years income, insurance, 20.2–23.0) or endoscopy: 

retrospective, (self-report) MD visit in past 22.2% (95% CI, 20.9– 

national year, years in US, 23.6) had not received a 

urban/rural MD recommendation. 

Surveys of doctors 

(PCPs) and patients 

(from NHIS), data 

collected 1999­

2000, for patients 

≥ 50 

N = 1,235 PCPs 

N = 6,497 adults 

Fair 

Wee et al., 2005111 FOBT in past Physician Age, race or ↓ No physician Reasons that respondents 

year; FS in past not ethnicity, recommendation did not have a FOBT (of 

Cross-sectional, 5 years; or recommending educational level, 9017), 22% reported their 

retrospective, colonoscopy in screening region of the physician did not 

National past 10 years country, and body recommend; for 

(self-report) weight as FS/colonoscopy, 21% 

NHIS, 2000, classified into reported their physician 

50-75 years standard BMI did not recommend. 

categories, family 

N = 11,427 history of CRC, 

healthcare access, 

Fair smoking status, 

and illness burden. 

AOR, adjusted odds ratio; CI, confidence interval; CRC, colorectal cancer; FOBT, fecal occult blood test; FS, flexible sigmoidoscopy; HINTS, 

Health Information National Trends Survey; MD, medical doctor; NHIS, National Health Interview Survey; P, probability; PCP, primary care 

physician; US, United States. 

* Arrow symbols (↓or ↑) are provided as a quick reference point of overall findings and represent the association reported 

between each variable and CRC screening. 

The NHIS cancer control module for CRC did not change between 2000 and 2005; results 

from the analyses of these two surveys were similar. All five of the NHIS studies assessed the 

percentage of people who had not had a screening test within the recommended interval and who 

reported that they had not had a physician recommendation to be tested within the past year. One 

study also examined data on 1,235 primary care physicians from the Survey of Colorectal Cancer 

Screening Practices, a 1999-2000 nationally representative survey of primary care and specialty 

physicians and health plan medical directors.57 

The 2002-2003 HINTS survey was a nationally representative random-digit dialing telephone 

survey of 6,369 noninstitutionalized civilians ages 18 and older, with over-sampling of blacks 

and Hispanics. Respondents who had not been screened within the recommended time interval 

(1 year for FOBT, 5 years for FS, and 10 years for colonoscopy) were asked an open-ended 

question about reasons for not being screened. The reasons were later aggregated into 12 

predefined categories for analysis. Among the categories was lack of physician 

recommendation.55-56 One HINTS study56 primarily examined CRC screening in the uninsured 

96 
(ages 50 to 64 years); the other assessed CRC screening in older respondents (ages 65 to 89 

years).55 

Overview of results of national studies. For people who had not had a screening test in the 

recommended interval but who had a physician whom they had visited within the past 12 

months, three studies agreed that from 92 percent to 94.6 percent had not received a physician 

recommendation for screening in that year.21,111,159 The fourth NHIS 2000 study compared 

reasons for low screening rates given by NHIS participants and those given by primary care 

physicians from the 1999-2000 Survey of Colorectal Cancer Screening Practices.57 Thirty-seven 

percent of physicians and 20 percent of NHIS participants cited failure of physician 

recommendation as a primary reason for low screening rates. As in the three other studies from 

the NHIS 2000, this study also found that among those respondents who had not been screened 

and who had seen a physician within the past year, about 90 percent had not received a 

recommendation for screening over that year.57 The NHIS 2005 study found results almost 

identical to the NHIS 2000 studies.46 

One HINTS study found that 75 percent to 85 percent had not been advised to be screened 

over this year.55 The other HINTS analysis examined barriers to CRC screening among the 

uninsured and found that about 91 percent of uninsured people who had received a physician 

recommendation for screening had in fact been screened; only 13 percent of uninsured 

respondents who had not received a recommendation had been screened (P < 0.001). 

Study characteristics of regional studies. Of the five regional studies, all rated as fair quality 

(Table 26),107,136,142,148,153 four were telephone surveys of people in three different areas: two 

studies from Massachusetts;107,153 one from Maryland; 148 one from Iowa; 136 and one from 

Genessee County, Michigan.142 These studies included one that called respondents who had 

responded to the 1999 BRFSS,153 and findings from either a state-based,107,148 or county-based 

health survey.142 One other study was a project that combined patient surveys and medical record 

reviews from family practices in rural Iowa.136 The study from Iowa matched a 2004 mailed 

survey of 511 patients (53 percent response rate) with a medical record review.136 

Table 26. Regional studies of the association of physician recommendation with CRC screening 

Author, Year, 

Study Design, Primary 

Population, Outcomes of Potential Variables 

Setting, Sample Interest for Predictors Confounders Associated with 

size, Quality Review Examined Considered CRC Screening Results (95% CI) 

Brawarsky et al., 

2004153 

Cohort, state 

Massachusetts 

BRFSS and a 

CRC call-back 

study, 1999, ≥ 50 

N = 779 

Fair 

FOBT in past Physician Age, education, No comparison 75% had received 

year, FS in past recommendation gender group a physician 

5 years, recommendation; 

colonoscopy in 81% who had a 

past 10 years recommendation 

(self-report) adhered to testing 

97 
Table 26. Regional studies of the association of physician recommendation with CRC screening (continued) 

Author, Year, 

Study Design, 

Population, Independent Predictors of 

Setting, Sample Primary Variables of Potential CRC screening 

size, Quality Outcomes Primary Interest Confounders Identified Results 

Gilbert et al., 

2005148 FOBT in past 

year; FS in past 

Ever had 

recommendation 

Age, gender, race, 

ethnicity, SES, 

↑ Physician 

recommendation 

Those who ever had 

physician 

5 years; or for FOBT, FS, or marital status, recommendation 

Cross-sectional, colonoscopy in colonoscopy health status, were more likely to 

retrospective, past 10 years personal and have completed the 

state (self-report) family risk factors FOBT (AOR, 70.72; 

95% CI, 66.56­

Maryland Cancer 77.45); FS (AOR 

Survey, 2002, 50­ 17.41; 95% CI, 

64 years 14.9-20.25); or 

colonoscopy (AOR 

N = 2,994 57.32; 95% CI, 

53.82- 60.75). 

Fair 

Janz, et al., 

2003142 FOBT in past 

year and FS in 

Physician 

recommendation 

Relevant 

sociodemographic 

↑ Physician 

recommendation 

Between 54 and 

65% of respondents 

past 5 years; OR and related factors indicated that their 

Cross-sectional, colonoscopy in (unspecified) physician had 

retrospective, past 10 years recommended 

county residents (self-report) FOBT, and over 

in Michigan, 50­ 92% of those 

79 years subjects reported 

having had the test 

N = 355 (no P values or 

odds ratios 

Fair provided). 

Levy et al., 

2006136 Five FOBT 

within past 5.5 

Physician 

recommendation 

Personal or family 

CRC history, 

↑ Physician 

recommendation 

Patients who 

recalled physician 

years; FS or recommendation, recommendation for 

Cross-sectional, DCBE within sociodemographic testing were more 

retrospective, past 5.5 years; information (not likely than others to 

practice based colonoscopy in specified) have been screened 

past 10.5 years (AOR, 6.4; 95% CI, 

Iowa family (claims) 4.2-9.6). 

physicians 

(n = 16), 2004, 

55-80 years 

N = 511 

Fair 

Zapka et al., 

2002107 Any test (colonoscopy or 

MD ever 

recommended FS 

Gender, race, 

education, 

↑ Physician 

recommendation 

Persons 50-64 and 

≥65 were more 

Cross-sectional, 

barium enema 

within 10 years, 

employment 

status, income, 

likely to have 

received a FS if MD 

State FS within 5 marital status, had ever been 

years, and family history of recommended 

CHS, 1998, 

Residents of 

FOBT in the 

past year) (selfCRC, perceived health status 

(AOR, 13.44; 95% 

CI, 7.22-25.02 and 

Massachusetts, report) AOR 12.39; 95% CI, 

≥ 50 years 5.68-27.06, 

respectively, 

N = 1,002 P < 0.0001). 

Fair 

98 
AOR, adjusted odds ratio; BRFSS, Behavioral Risk Factor Surveillance System; CHS, Community Health Survey; CI, confidence interval; CRC, 

colorectal cancer; DCBE, double contrast barium enema; FOBT, fecal occult blood test; FQHC, federally qualified health center; FS, flexible 

sigmoidoscopy; MD, medical doctor; N, number; SES, socioeconomic status. 

*Arrow symbols (↓or ↑) are provided as a quick reference point of overall findings and represent the association reported 

between each variable and CRC screening.
 

Overview of results of regional studies. All five studies found a strong association between 

physician recommendation and receipt of CRC screening, much like those at the national level. 

Patient-Provider Communication 

Study characteristics. We found five cross-sectional studies, which we rated fair quality, 

pertaining to the association between patient-provider communication and CRC screening (Table 

27).56,135,140,154,167 Two used HINTS data to examine the association between communication and 

screening among the uninsured.56,135 Both used measures from the Consumer Assessment of 

Healthcare Providers and Systems (CAHPS®) to assess patient-provider communication; these 

address how well patients feel the provider listens to them, explains options, respects them, 

spends adequate time with them, and involves them in medical decision making. Another study 

used data from 8,488 survey respondents from the MEPS to examine the relationship between 

patient-provider communication and socioeconomic variables on the receipt of CRC 

screening;154 patient-provider communication was assessed by measures derived from CAHPS. 

Another study surveyed 397 Black church members in North Carolina;140 it assessed this factor 

with a “communication score” based on five patient-reported items. The final study surveyed 

female patients of primary care physicians in Los Angeles on their perceptions of how 

enthusiastically their provider recommended or discussed CRC screening with them.167 

Table 27. Studies of the association of patient-provider communication and CRC screening 

Author 

Year 

Study 

design 

Population 

Setting 

Sample size 

Quality Study Aims 

Primary 

Outcomes of 

Interest 

Predictors 

Examined 

Potential 

Confounders and 

Modifiers 

Considered 

Variables 

Associated 

with CRC 

Screening† Results (95% CI) 

Cairns et al., 

200656 Examine the 

role of 

Ever 

screened for 

Patientprovider None. A analyses 

of patient-provider 

No differences 

on interaction 

No 

communication 

communication FOBT, FS, or interaction communication variables measures were 

Cross- factors and colonoscopy based on five were bivariate and significantly 

sectional, insurance, with (self-report) CAHPS did not adjust for related to CRC 

national a specific focus measures* potential screening status. 

sample, on the confounders 

HINTS uninsured, to 

examine 

Ages 50-64 disparities in 

CRC screening 

1,253 

Fair 

99 
Table 27. Studies of the association of patient-provider communication and CRC screening (continued) 

Author 

Year 

Study design 

Population 

Setting 

Sample size 

Quality Study Aims 

Primary 

Outcome 

Measurement 

of Independent 

Variable of 

Primary 

Interest 

Potential 

Confounders 

and Modifiers 

Variables 

Associated 

with CRC 

Screening† 

Results (95% 

CI) 

Carcaise- Examine the Ever Patient-provider Age, sex, race, ↑ Enough time Those who 

Edinboro et 

al., 2008154 relationship 

between 

screened for 

CRC by 

communication 

assessed by 

education, 

geography, 

with provider 

for any test 

reported that 

they 

patient-provider FOBT, measures metropolitan sometimes, 

Cross- communication colonoscopy, derived from statistical area, ↑ MD usually, or 

sectional, and or FS in CAHPS insurance status, adequately always have 

national socioeconomic lifetime (self­ family income, explains enough time 

sample variables on report) usual source of information for with the 

Medical the receipt of care, self- FOBT provider were 

Expenditures CRC reported health, more likely to 

Panel Survey screening) be screened by 

(MEPS) any test (AOR 

range, 2.61- 

Age 50 years 2.99). 

or older 

Those who 

8,488 reported that 

their provider 

Fair sometimes, 

usually, or 

always 

adequately 

explains 

information 

about FOBT 

were more 

likely to report 

being screened 

(AOR 

range, 3.67 to 

6.42). 

Fox et al., 

2009167 Examine the 

separate 

FOBT within 

past year 

Level of 

enthusiasm 

Race, ethnicity, 

income, 

↑ Low level of 

enthusiasm 

Patients who 

perceived a low 

contributions of provider showed education, from MD for level of 

Cross- patients and in discussion insurance, FOBT (vs. no enthusiasm 

sectional, physicians to about FOBT discussion) from provider 

retrospective, their were more 

local communication likely to 

regarding complete 

Survey of cancer FOBT than 

women screening those who 

patients of 63 reported no 

PCP in Los discussion 

Angeles, 50 (AOR, 6.426; 

years or older P < 0.0001). 

For those who 

N = 904 perceived high 

enthusiasm, 

Fair the relationship 

to screening 

was not 

significant. 

100 
Table 27. Studies of the association of patient-provider communication and CRC screening (continued) 

Author 

Year 

Study 

design 

Population Measurement 

Setting of Independent Variables 

Sample Variable of Potential Associated 

size Primary Primary Confounders with CRC Results (95% 

Quality Study Aims Outcome Interest and Modifiers Screening† CI) 

Katz et al., Determine the Undergoing Communication Sex, source of ↑ Quality of Quality of 

2004140 relationship FOBT, score used to health care, communication communication 

between the colonoscopy, categorize knowledge of (good vs. 

Cross- general quality FS within the quality of CRC risk poor/fair 

sectional, of patient-rated recommended communication communication 

church- patient- time period as good, fair, or scores) were 

based, 1 provider (self report) poor; based on significantly 

state (North communication five items associated with 

Carolina) and the (abbreviated improved 

completion of versions here): completion of 

Age 50 CRC screening (1) receive CRC screening: 

years or understandable OR 1.95 

older information from (95% CI, 1.29-

doctor 2.94). 

397 (2) feel rushed 

during visits 

Fair (3) feel your 

doctor allows 

you to become 

involved 

(4) feel 

uncomfortable 

asking doctor 

about tests 

(5) feel that your 

doctor 

understands 

your health 

needs 

Ling et al., Assess the CRC Respondents Age, sex, race, No differences The up-to-date 

2006135 association screening up were asked five highest based on and not up-tobetween to date or not CAHPS* education level, provider-patient date groups did 

Cross- provider- (self-report); measures. tobacco use, interaction not differ 

sectional, patient considered up household significantly on 

national interaction and to date if income ↑ Trust in cancer any patientsample, CRC screening FOBT in past information provider 

HINTS utilization year or FS or provided interaction item. 

colonoscopy 

Age 51 in past 10 Having trust in 

years or years cancer 

older information from 

the doctor was 

2,670 associated with 

being up-to-date 

Fair with CRC 

screening: 

AOR 2.08 (95% 

CI, 1.49-2.94). 

AOR, adjusted odds ratio; CAHPS, Consumer Assessment of Healthcare Providers and Systems; CI, confidence interval; CRC, colorectal cancer; 

FOBT, fecal occult blood test; FS, flexible sigmoidoscopy; HINTS, Health Information National Trends Survey; MD, medical doctor. 

101 
*CAHPS measures: During the past 12 months, how often did doctors or other health care providers: listen carefully to you, explain things in a 

way you could understand, show respect for what you had to say, spend enough time with you, involve you in decisions about your health care as 

much as you wanted]? Would you say always, usually, sometimes, or never? 

†Arrow symbols (↓or ↑) are provided as a quick reference point of overall findings and represent the association reported 

between each variable and CRC screening. 

All five studies measured patient-provider communication as perceived by patients. In 

addition, all five used patient-reported CRC screening status as their primary outcome. One 

study also assessed subject’s trust in cancer information from the doctor.135 

Overview of results. The two national studies that used HINTS data reported no significant 

association between patient-provider communication measures (from CAHPS) and CRC 

screening status.56,135 However, the MEPS-based study demonstrated that patients who reported 

that their provider spent enough time with them and adequately explained information were 2.6 

to 6.4 times more likely to have undergone CRC screening.154 The North Carolina study reported 

that better quality of patient-provider communication was significantly associated with 

completion of CRC screening.140 The fifth study of women of PCP physicians in Los Angeles 

found that even a discussion with the provider with perceived ‘low enthusiasm’ for testing was 

significantly more likely to result in testing than no discussion about testing (AOR, 6.246; 

P < 0.0001).167 One other study (presented in the patient level factors section) also supported a 

positive relationship between patient-provider communication and any CRC screening.144 

One of the HINTS studies reported that subjects having trust in cancer information from the 

doctor were more likely to be up-to-date with CRC screening (OR = 2.08, 95% CI, 1.49-2.94).135 

Another study, highlighted in the patient level factors section on insurance status also reported a 

positive relationship between adherence to FOBT and patient’s report that their provider 

demonstrates compassion.128 

Periodic Health Examinations 

Study characteristics. We found one study, which we rated as fair quality, that focused on 

the association between receipt of a periodic health examination (PHE) and CRC screening rates 

(Table 28).164 It was a retrospective cohort study of 64,288 consecutive enrollees in a 

Washington state health plan who had attended one or more primary care visits in 2002-2003 and 

had been eligible for one or more cancer screening tests (for CRC, breast cancer, or prostate 

cancer).164 It defined a PHE as any outpatient encounter (in 2002-2003) having either (1) an 

evaluation and management code indicating “initial evaluation” (codes 99386-7) or “reevaluation 

and management of a healthy individual” (codes 99396-7) or (2) an International Classification 

of Diseases, Ninth Revision, Clinical Modification, code signifying either a general medical 

examination (code V700 or V708-9) or a gynecologic examination (code V723). The study 

reported results for a combined outcome of either FOBT or invasive CRC testing (FS, 

colonoscopy, or barium enema). 

Overview of results. A greater proportion of subjects who had had a PHE received CRC 

screening than subjects who had not had a PHE (unadjusted: 57.2 percent versus 17.2 percent, 

respectively).164 The incidence of CRC testing was more than three times higher in patients who 

received PHEs than in those who did not (adjusted relative incidence, 3.47; 95% CI, 3.34-3.59; 

P < 0.001).164 

Results from several other studies in this review supported the finding that subjects having 

periodic health examinations, annual physicals,134 physicals,171 health maintenance 

examinations,136 or annual checkups108,153,172 are more likely to have had CRC screening than 

people not receiving such services. We do not describe these studies in further detail or include 

102 
them in the table because they were not designed to focus on this factor (PHEs); rather, they 

primarily examined another factor or examined multiple factors simultaneously. 

Table 28. Studies of association between periodic health examination (PHE) and CRC screening 

Author 

Year Measurement 

Study design of 

Population Independent Association 

Setting Variable of Potential of Variables 

Sample size Primary Primary Confounders to CRC 

Quality Study Aims outcome Interest and Modifiers Screening* Results 

Fenton et al., 

2007164 

Retrospective 

cohort, 1 state 

Enrollees in a 

Washington 

State health 

plan 

N = 64,288 

Fair 

Determine the 

association 

between 

receipt of a 

PHE and 

completion of 

cancer 

screening 

Completion of 

either FOBT 

(based on 

automated 

laboratory 

data) or 

invasive 

testing (FS, 

colonoscopy, 

or barium 

enema; based 

on CPT codes 

from outpatient 

and inpatient 

encounters) in 

2002-2003 

PHE, from 

evaluation and 

management 

codes or ICD9 

codes 

Adjusted for 

age, sex, 

comorbidity 

(Charleson 

comorbidity 

index), number 

of outpatient 

visits, baseline 

PHE receipt, 

baseline 

number of 

target organ 

cancer tests, 

and significant 

interactions 

between PHE 

receipt and the 

listed 

covariates 

↑ PHE Of those who 

received a 

PHE, 57.2% 

received CRC 

testing vs. 

17.2% of 

those who did 

not receive a 

PHE (AOR, 

3.47; 95% CI, 

3.34-3.59; 

P < 0.001) 

AOR, adjusted odds ratio; CRC, colorectal cancer; FOBT, fecal occult blood test; FS, flexible sigmoidoscopy; CPT, current procedural 

terminology; ICD-9, International Classification of Diseases, Ninth revision; N, number; P, probability; PHE, periodic health examination. 

* Arrow symbols (↓or ↑) are provided as a quick reference point of overall findings and represent the association reported between each variable 

and CRC screening. 

System Level Factors Associated With CRC Screening 

This part of KQ 2 focuses on health care system characteristics associated with CRC 

screening, CRC screening discussions, or the quality of CRC screening. The issue we addressed 

is whether the organization of health care services influences CRC screening. Thus, we searched 

for studies of any research design that examined the association between system characteristics 

and any of our three primary outcomes (measured in a valid and reliable manner): CRC 

screening rates, the frequency or quality of CRC discussions, or the quality of CRC screening. 

By health care system characteristics, we are referring to such variables as involvement of 

nonclinician staff in screening, the practice’s being part of a managed care organization, use of 

reminder or recall systems, having an organized endoscopy referral system, the size and/or type 

of the medical practice, and the degree of local autonomy over the structure of care delivery. We 

distinguish between these system characteristics and other factors, such as patient access to 

health care (including having health insurance or having a regular source of health care), 

characteristics of the patient-clinician interaction (including trust or having health maintenance 

visits), or receiving a clinician recommendation for screening. 

Study characteristics. We found six fair-quality studies that provided some information 

about this question.66,110,127,139,143,173 Three studies used large datasets (one including 155 VA 

primary care clinics),110 another used Medicare claims data,139 another used Medicare claims 

103 
data plus a national physician survey,127 while the sixth used survey data to compare patients 

who receive their regular care from county health centers versus those going to a private 

physician office in the New York City area.66 Two studies collected data from medical 

practices.143,173 One of the latter studies focused on 22 suburban primary care practices in New 

Jersey and Pennsylvania,143 and another examined a single primary care practice within a lowincome urban New York City setting.173 Five studies were cross-sectional,66,110,127,139,143 and the 

sixth was a cohort study.173 

The six studies examined a variety of system variables, including involvement of 

nonclinician staff in screening, reminder systems, endoscopy referral systems, local autonomy of 

the internal structure of care delivery, size or type of the practice, group versus solo practice, and 

degree of managed care activity in the area. All used the outcome of CRC screening (according 

to national screening guidelines), assessed either through administrative databases,127,139,173 

through direct medical record review,110,143 or self-report via telephone surveys.66 

Overview of results. Five of the six studies reported a positive association between some 

system characteristic and CRC screening (Table 29). The most positive associations were use of 

nonphysician staff (for either general counseling143 or assistance with the screening process173). 

In one study, a practice’s use of nonphysician staff for general lifestyle counseling was 

associated with a near-doubling of CRC screening (from 27.2 to 54.1 percent points);143 in 

another, nonphysician “patient navigators” (along with several other administrative changes) 

increased the number of patients receiving colonoscopy each month from 75.7 to 119.0.173 

Table 29. Studies of the association between system level factors and CRC screening 

Author, Year, 

Study Design, 

Population, 

Setting, Sample 

Size, Quality 

Yano et al., 2007110 

Primary 

Outcomes 

Abstracted data on 

Independent 

Variables of 

Primary Interest 

Centralization 

Potential 

Confounders 

Patient and 

Association 

of Variables 

to CRC 

Screening*

↑

 Results 

Autonomy over 

colonoscopy, (authority over clinician Centralization internal structure 

Cross-sectional, FOBT, FS; overall operations, staffing, characteristics, (i.e., (P < 0.04), clinical 

retrospective, VA screening rate etc.), resources health care autonomy), support (P < 0.03), 

based (claims) (sufficiency of use resources and smaller size 

nonclinician (i.e., clinical (P < 0.001) were 

Data collected 1998 staffing, space, support), and statistically 

and 2001 clinical support), complexity significantly 

and complexity (i.e., facility associated with more 

Primary care (facility size, size) CRC screening. 

directors survey, academic status, 

155 VA primary care managed care) of 

clinics across organization 

country, 1999-2000 

and 38,818 patient 

claims data (2001) 

Fair 

104 
Table 29. Studies of the association between system level factors and CRC screening (continued) 

Author, Year, 

Study Design, Association 

Population, Independent of Variables 

Setting, Sample Primary Variables of Potential to CRC 

Size, Quality Outcomes Primary Interest Confounders Screening* Results 

Hudson et al., Colonoscopy, Use of nursing or Physician, ↑ Counseling CRC screening 

2007143 FOBT, and FS; health educator patient, from non- rates: 

overall screening staff to counsel interaction, clinician staff, Use of nonclinician 

Cross-sectional rate patients about diet, and other use of staff for counseling: 

study, retrospective, exercise, or tobacco practice reminder • Yes: 54.1% 

practice based use characteristics; systems • No: 27.2% 

variation in [AOR, 2.96

22 family practices, Use of patient types of (95% CI, 2.21­

NJ and PN, 2003- reminder systems reminders 3.96)]

2004 of any type (not used 

specifically for CRC Reminder systems: 

N = 795 screening) • Yes: 39.9% 

• No: 19.6% 

Fair [AOR, 2.57 

(95% CI, 1.77­

3.74)] 

Koroukian et al., Colonoscopy, County-level Patient, ↑ Managed Greater level of MCA 

2005139 FOBT, FS assessment of physician, and care among associated with CRC 

(claims) MCA, based on % interaction Medicare FFS screening: 

Cross-sectional Medicare patients characteristics; patients High vs. low MCA: 

study, retrospective, on managed care in practice • FOBT: AOR, 

national each US county: organizational 1.10 (95% CI, 

characteristics; 1.04-1.16) 

Association of High: > 30% only have • Colonoscopy: 

county-level Moderate: 10- county-level AOR, 1.07 

assessment of 29.9% data on patient (95% CI, 1.03­

managed care Low: < 10% and physician 1.10)

(MCA) with characteristics • FS: AOR, 0.98 

Medicare FFS (95% CI, 0.93­

patients, 1998-1999, 1.03)

≥ 65 

No absolute 

N = 23 million screening rates 

given. 

Fair 

Messina, et al., 

200966 

Cross-sectional, 

retrospective, local 

Telephone survey of 

random samples of 

patients of CHC 

compared to those 

of PPO offices in the 

New York City area, 

52- 75 years of age 

FOBT within past Type of provider Gender, race/ 

year, FS in past 5 (CHC or PPO) ethnicity, 

years, education, 

colonoscopy in income, 

past 10 years insurance, 

(self-report) health status 

↓ CHC 

patients 

compared to 

PPO patients 

for endoscopy 

screening 

↑ CHC 

patients 

compared to 

PPO patients 

for FOBT 

FOBT was more 

frequent among CHC 

patients; FS and 

colonoscopy were 

more frequent 

among PPO patients 

(P < 0.001) 

CHC patients less 

frequently cited no 

physician 

recommendation as 

a barrier to FOBT, 

but more frequently 

cited no 

105 
Table 29. Studies of the association between system level factors and CRC screening (continued) 

Author, Year, 

Study Design, 

Population, 

Setting, Sample 

Size, Quality 

Primary 

Outcomes 

Independent 

Variables of 

Primary Interest 

Potential 

Confounders 

Association 

of Variables 

to CRC 

Screening* Results 

Messina, et al., 

200966 recommendation as 

a barrier to FS and 

(continued colonoscopy, 

compared with PPO 

N = 1070 patients (p<0.02). 

Fair 

Nash et al., 2006173 Monthly rate of Intervention Societal, ↑ Patient Broken colonoscopy 

screening included (1) two independent navigation appt rate decreased 

Retrospective cohort colonoscopy, “patient navigators” increase in (due to from 67.2% before 

analysis, before and broken- to assist patients in colonoscopy reduced intervention to 5.3% 

after an appointment (appt) obtaining a happening at broken after intervention. 

organizational rate for colonoscopy, same time; appoint- The broken 

intervention (no colonoscopy providing continuity other ments) appointment rate 

control group), data (claims) between cointerven­ started immediately 

collected 2003-2004 departments as tions (e.g., after patient 

patients navigated public navigators hired and 

Single medical the system; information at before DERS was in 

center in New York (2) new DERS to same time) place. 

City allow PCP to refer also possible 

patients directly for 

Fair colonoscopy; and 

(3) GI suite 

enhancements to 

improve operational 

efficiency (e.g., 

more 

colonoscopies, 

efficient 

colonoscope 

cleaning, more 

nurses in procedure 

Pham et al., 2005127 One-year rates of 

rooms) 

Patient Patient No No statistically 

colonoscopy or characteristics (e.g., comorbidity, associations significant 

Cross-sectional, FS, excluded age) from Medicare individual found association between 

retrospective, FOBT because file, some patient income and CRC screening 

national claims data not variables (e.g., other among patients 

reliable income) from zip demographic cared for by 

Physician survey code data and education physicians in 

and Medicare claims factors; doctor- different practice 

data, 2000-2001 Physician and patient types (e.g., 

practice interaction medium/large group 

N = 3,660 characteristics from factors; vs. solo/two-person 

physicians and CTS physician managed care group: AOR, 1.12 

24,581 patients survey, focus on practice [95% CI, 0.90-1.38]). 

primary care factors 

Fair physicians Patients cared for by 

physicians with 

Practice access to reminders 

characteristics were not more likely 

106 
Table 29. Studies of the association between system level factors and CRC screening (continued) 

Author, Year, 

Study Design, 

Population, 

Setting, Sample 

Size, Quality 

Primary 

Outcomes 

Pham et al., 2005127 

Independent 

Variables of 

Primary Interest 

including use of 

Potential 

Confounders 

Association 

of Variables 

to CRC 

Screening* Results 

to have been 

(continued) computerized screened: 5.8% with 

physician reminders vs. 5.9% 

reminders, size and without reminders 

type of the practice (adjusted AOR, 0.96 

[95% CI, 0.84-1.09]). 

CI, confidence interval; CRC, colorectal cancer; CTS, Community Tracking Study; DERS, Direct Endoscopic Referral System; FFS, fee-forservice; FOBT, fecal occult blood test; GI, gastrointestinal; MCA, managed care activity; N (n), number; AOR, adjusted odds ratio; PCP, primary 

care physician; SES, socioeconomic status; US, United States; VA, Veterans Administration; vs., versus; MCA, managed care; CHC, county 

health center; PPO, private physician offices. 

* Arrow symbols (↓or ↑) are provided as a quick reference point of overall findings and represent the association reported between each variable 

and CRC screening. 

Two other studies found what appears to be moderate increases in CRC screening associated 

either with higher levels of managed care activity in the area139 or with a higher level of 

autonomy over the internal structure of the practice.110 Although both findings were statistically 

significant, determining the exact strength of the association in these studies is difficult because 

they did not provide absolute screening rates. 

Use of patient reminders was associated with a higher level of CRC screening in one study 

(39.9 percent versus 19.6 percent).143 However, the availability (rather than the use) of 

computerized physician reminders was not associated with a higher screening rate after 

adjustment for practice size and patient covariates.127 

In addition, one study found that smaller practices (within a group of large practices) were 

associated with higher screening rates (although absolute rates were not given).110 After 

adjusting for other patient and physician covariates, investigators on another study found no 

association between practice size among smaller practices (solo/two-person group practice 

versus larger group practice) and CRC screening (5.9 percent versus 5.8 percent 1-year screening 

rates).127 The final study found higher endoscopy screening rates among patients of private 

physician offices compared to those receiving care in the same geographic region through county 

health centers (P < 0.001).66 This study also found that patients of county health centers were 

more likely to cite no physician recommendation as a barrier to endoscopy when compared to 

patients of private physician offices (P = 0.02).66 

Summary 

We categorized studies examining factors associated with the use of CRC screening tests into 

five domains: 1) patient factors, 2) physician factors (including physician characteristics, 

physician-patient connectedness, and physician recommendations about screening), 3) patientphysician communication factors, 4) the periodic health examination, and 5) system level factors. 

We further categorized the patient factors into four groups: patient demographics, access to care, 

personal health or risk factors, and psychosocial factors. 

All included studies focused on factors associated with underuse of CRC screening. None 

focused on factors associated with underuse of CRC discussions or on factors associated with 

overuse or misuse of CRC screening. 

Several factors are consistently and significantly associated with reduced CRC screening 

(i.e., P < 0.05 or confidence intervals that do not overlap or include 1.0). They include: 

107 
•	 Low household income 

•	 No health insurance 

•	 Being Hispanic or Asian 

•	 Not being acculturated into the United States 

•	 Limited access to care (i.e., lack of a regular source of primary care and no visits in 

previous year to provider), and 

•	 No physician recommendation to be screened. 

Factors positively associated with CRC screening include having private insurance, being 

non-Hispanic white, higher education level, participating in regular screenings for other cancers, 

having a family history of CRC or personal history of another cancer, having regular access to 

care, having effective provider-patient communication, or physician recommendation. We found 

one study each that examined the association between screening and specific physician 

characteristics, physician-patient connectedness, and use of periodic health examinations. Thus, 

insufficient evidence exists to draw conclusions about these relationships. Studies on system 

level factors that might influence CRC screening did not consistently measure the same variables 

but seem to support counseling by nonclinicians, reminder systems, and assisting patients to keep 

appointments. 

KQ 3: Which Strategies Are Effective In Increasing The 

Appropriate Use Of Colorectal Cancer Screening And 

Followup? 

KQ 3 focuses on the evidence on effectiveness of strategies that have attempted to increase 

appropriate CRC screening and followup. Therefore, all included studies measured the outcome 

of CRC screening and/or followup rates; one also included the outcome of a discussion with a 

provider about screening. 

We classified strategies into those that targeted the patient, the provider, the health system, 

and/or the community. We identified and included 15 studies that targeted the patient,85,174-187 

2 that targeted the provider,186,188 and 5 (six manuscripts) that targeted the health care 

system.162,189-193 (Some studies had more than one focus.) We found no RCTs of either fair or 

good quality that tested interventions implemented within a community. Of these 21 studies in 

all, one focused on appropriate followup after an abnormal screening;188 the others focused only 

on increasing screening rates. 

We present only those studies that we rated as fair or good quality. Common reasons that we 

rated studies as poor quality included a combination of issues. For example, the randomization 

process was not explained, was difficult to determine, or was not blinded to the provider; the 

response rate was low (< 60 percent); the investigators used nonstandard instruments or outcome 

measures to assess screening or followup rates; and/or the comparison samples were dissimilar 

on key characteristics at baseline. 

Our overall summary and strength of evidence tables for studies addressing this KQ are 

presented at the beginning of this section. The remainder of this section provides, first, an 

overview of studies of patient-level interventions. We then consider the two studies of a 

provider-level intervention186,188 and the five studies of a system-level intervention.162,189-193 

108 
KQ 3 Overall Summary and Strength of Evidence 

In the tables that follow, our overall grades of the strength of evidence appear in the far right 

column; grades for key domains to determine the strength of evidence are in the intermediate 

columns. Table 2 (Chapter 2) defined terms used to describe the strength of evidence; these 

definitions can also be found in the glossary for this report. 

We included 21 RCTs, rated good or fair quality, of interventions designed to increase CRC 

screening. These included 15 studies that targeted the patient,85,174-187 2 that targeted the 

provider,186,188 and 5 (including two manuscripts of the same study) that targeted the health care 

system.162,189-193 

Following categories similar to those recently used to develop recommendations by the Task 

Force on Community Preventive Services (TFCPS) on CRC screening,194 we divided the types of 

studies of interventions targeting patients into five categories: (1) patient reminders;175,182-183,186 

(2) small media (with177-178,181 and without174-176,185 decision aids); (3) group education;184-185 

(4) one-on-one interaction;85,179-180 and (5) reducing structural barriers.85,175,179,183,186-187 Much 

like recommendations for the Guide to Community Preventive Services,194 these studies include 

five that have more than one type of intervention.85,175,179,183,185 For each of these, we categorized 

them into more than one type of intervention in determining the strength of evidence and 

presenting the overall findings in the following sections. When possible, we attempted to 

evaluate the incremental contribution of each component separately. However, for most studies, 

the effect of all the components was evaluated collectively, such that findings were not presented 

by authors in a way that allowed us to assess the incremental impact of adding each component. 

Across these 15 RCTs focused on patient-level interventions, the range of increases in screening 

was 0 percent to more than 40 percentage points.85,174-187 

As shown in Table 30, we found high strength of evidence that interventions that provide 

patient reminders lead to small to moderate increases in screening (percent increases ranged from 

5.0- 15 percentage points).175,182-183,186 We also found high strength of evidence that of small 

media, such as delivery of education videos or brochures to patients before being seen by a 

physician or in the mail through a church registry list, have little to no impact on screening 

rates.174-176,185 Use of decision aids, delivered via small media, was less conclusive. Although we 

recognize that not all decision aids are equal, with some designed to be more interactive with 

patients than others, we found the evidence to be mixed in terms of how effective they are in 

increasing screening (rate change in percentage points from 3 percent [P = 1.0181] to 14.2 

percent177 and 23 percent178). For this mixed evidence, with two of three studies showing benefit, 

we concluded that the strength of evidence is low (because of the inconsistent results) that some 

types of decision aids are effective for increasing screening. We identified two studies examining 

the impact on CRC screening rates of group education delivered either by Native Hawaiians 

among Native Hawaiians184 or by African Americans for their fellow church members on the 

need for testing.185 These studies demonstrated mixed effects; one showed a negative finding on 

the impact of the intervention on screening184 and another finding a borderline positive effect 

(P = 0.08),185 we concluded that the strength of evidence is low for this intervention type. The 

two remaining categories of patient level interventions (one-on-one interventions and eliminating 

barriers) both provided high strength of evidence that they yield an increase in screening rates. 

The interventions designed to provide one-on-one interactions, through either a nurse, or health 

educator,85,179 or on the phone,180 hold promise in their ability to increase CRC screening, with 

109 
Table 30. Effect of patient-level interventions on CRC screening rates 

Risk of 

Bias Overall 

Number of Studies; # of 

Subjects 

Design/ 

Quality Consistency Directness Precision Results 

Strength 

of 

Evidence 

Patient Reminders 

Denberg et al., 2006182 

Myers et al., 2007175 

Church et al., 2004183 

Sequist, et al., 2009186 

Low 

4 RCTs/ 

1 Good, 

Consistent Direct Precise 

Patient reminders 

are effective vs. no 

intervention (5.0 - 

15 percentage 

High 

3 Fair point increase in 

4: 25,442 screening rates). 

Zapka et al., 2004174 

Myers et al., 2007175 

Costanza et al., 2007176 

Campbell, et al., 2004185 

Low 

4 RCTs/ 

1 Good, 

Small Media (only) 

Consistent Direct Precise 

Small media (i.e., 

providing education 

to patients without 

specific decision 

High 

3 Fair aids) do not seem 

4: 5,245 to be effective. 

Ruffin et al., 2007178 

Dolan and Frisina, 2002181 

Pignone et al., 2000177 

3: 518 

Low 

Small Media/Decision Aids 

Mixed results such Low 

that 2 of 3 studies 

3 RCTs/ 

1 Good, 

2 Fair 

Inconsistency 

present 

Direct Imprecise found decision aids 

to be beneficial 

versus no or limited 

interventions (14 - 

23 percentage point 

increase in 

screening rates 

reported in the two 

positive studies). 

Group Education Interventions 

Braun, et al., 2005184 Low Group education Low 

Campbell, et al., 2004185 Consistent Direct Imprecise interventions were 

2: 409 2 RCTs/ not more effective 

2 Fair than comparisons 

for increasing 

screening rates. 

One-on-one Interventions 

Basch et al., 2006180 

Stokamer et al., 200585 

Tu et al., 2006179 

3: 1,545 

Tu et al., 2006179 

Stokamer et al., 200585 

Myers et al., 2007175 

Church et al., 2004183 

Potter, et al., 2009187 

5: 4304 

Low 

3 RCTs/ Consistent Direct Precise 

1 Good, 

2 Fair 

Eliminating Barriers 

Low 

5 RCTs/ Consistent Direct Precise 

2 Good, 

3 Fair 

One-on-one High 

interactions were 

effective in 

increasing CRC 

screening rates 

(14.6 - 41.9 

percentage point 

increase). 

Eliminating barriers High 

for increasing CRC 

screening was 

effective vs. no 

intervention (14.6 - 

41.9 percentage 

point increase in 

any CRC test use). 

CRC, colorectal cancer; RCT, randomized controlled trial. 

110 
percentage point increases ranging from 14.6 percent in FOBT completion,85 20.9 percent of any 

CRC test through repeated telephone counseling, and 41.9 percent in FOBT completion through 

an intervention provided by a bi-lingual health educator.179 Those designed to eliminate barriers 

by providing FOBT tests to use at home or providing access to individuals who can help to 

address barriers were also shown to be effective in increasing screening rates (rate change from 

14.6- 41.9 percentage points).85,175,179,183,187 

We also address discussions with providers as an outcome for KQ 3 and found one study that 

presented findings specific to increases in this outcome (Table 31).177 These investigators 

reported 25.1 percent increase in discussions (Table 31), but with only one study we concluded 

that there is low overall strength of evidence for patient-level interventions to increase 

discussions with providers. 

Table 31. Effect of patient-level intervention on discussions with providers 

Overall 

Number of Studies; Risk of Bias 

Strength 

of 

# of Subjects 

Pignone et al., 2000177 

Design/Quality Consistency Directness 

Low Consistency Direct 

Precision Results 

Imprecise One study favored 

Evidence 

Low 

Unknown use of small media 

1: 651 1 RCT/ (single study) with or without 

1 Fair decision aids vs. no 

intervention in 

increasing 

discussions with 

providers (25.1 

percentage point 

difference). 

RCT, randomized controlled trial. 

In addition to the 15 studies of patient level interventions, we included 2 studies on provider 

level interventions (Table 32).186,188 One study on provider-level interventions sent reminders to 

physicians who had patients in need of surveillance colonoscopies;188 the other study used 

electronic reminders during patient office visits to increase ordering of the tests.186 The first 

study favored providing reminders to physicians to increase surveillance colonoscopies, but the 

other found no difference between CRC screening rates of patients whose providers received 

reminders or not (P = 0.47).186 We rated the strength of evidence as low because the included 

studies tended to indicate no benefit in provider reminders in increasing screening. 

Table 32. Effect of provider-level interventions on CRC screening rates 

Number of Studies; 

# of Subjects 

Ayanian, et al., 2008188 

Sequist, et al., 2009186 

2: 251 physicians: 

22,630 patients 

Risk of Bias 

Design/Quality Consistency Directness 

Low 

2 RCTs/ 

2 Good 

Inconsistent Direct 

Precision Results 

Imprecise Mixed results such 

that 1 study found a 

slight increase in 

surveillance 

colonoscopy and 

another study found 

no difference in CRC 

screening among 

patients whose 

provider received 

reminders. 

Overall 

Strength 

of 

Evidence 

Low 

RCT, randomized controlled trial; CRC, colorectal cancer. 

111 
The five studies (six articles) on system-level interventions162,189-193 implemented changes to 

improve referral of patients for screening190-192 or identified a person such as a patient 

navigator189 or someone in a similar role (i.e., Prevention Care Manager or PCM)162,193 to help 

patients navigate the health care system (Table 33). Their findings indicated that this intervention 

may provide promising effects on increasing CRC screening. 

The 21 studies identified as eligible for this KQ represented a small fraction of all studies 

reporting on interventions designed to improve CRC screening. These other (ineligible) studies 

were not conducted as a RCT design, provided a limited description of the intervention, or used 

untested or unvalidated measures in assessing outcomes. 

Table 33. Effect of system-level interventions on CRC screening rates 

Risk of 

Bias 

Overall 

Number of Studies; 

# of Subjects 

Jandorf et al., 2005189 

Dietrich, et al., 2007162 

Roetzheim, et al., 2004190 

Roetzheim, et al., 2005191 

Ling, et al.., 2009192 

Dietrich, et al., 2006193 

Design/ 

Quality

Low 

5 RCTs/ 

5 Fair 

 Consistency 

Consistent 

Directness 

Direct 

Precision 

Precise 

Results 

Strength of 

Evidence 

System- level 

interventions are 

effective in 

increasing CRC 

screening vs. no 

intervention 

High 

(7%-28.2% 

5: 9445 difference in 

screening rates). 

RCT, randomized controlled trial; CRC, colorectal cancer. 

Patient Interventions 

Study characteristics. Following categories similar to those that the TFCPS used to develop 

CRC screening recommendations,194 we divided the types of studies of interventions targeting 

patients into five categories: (1) patient reminders;175,182-183,186 (2) small media (with177-178,181 and 

without174-176,185 decision aids); (3) group education;184-185 (4) one-on-one interaction;85,179-180 and 

(5) reducing structural barriers.85,175,179,183,187 Table 34 Shows which studies employed which 

types of interventions; following this section and overview of results, we consider each kind of 

intervention in turn. 

Patient reminders can be in the form of written materials such as postcards, letters, or other 

materials used to remind or alert patients of their need for CRC screening. Reminders can also be 

provided through telephone contacts with patients who are due for screenings. These reminders, 

when used as an intervention, are provided to patients who are due for a rescreening or who have 

never been screened; they are not reminders of an upcoming appointment that is already 

scheduled. Patient reminders are thought to be a means of effectively prompting people about 

their need for annual screening (or for screening related to whatever period recommended for the 

patient); the idea is that if patients are not scheduled to see a provider, they will initiate an 

appointment in order to remain current on cancer screening tests. 

Small media interventions focus on providing respondents with educational materials; they 

can include videos and printed materials such as letters, brochures, and newsletters that are 

provided to patients explicitly to educate them about the disease under study (i.e., colorectal 

cancer), their risks for being diagnosed with the disease, and screening tests that are available. 

These materials are termed “small media” because they rely on mail, telephone, or distribution of 

112 
Table 34. Patient-level studies by category of intervention 

Small Media to Provide 

Education 

Included Articles 

with Patient-Level 

Interventions 

Patient 

Reminders 

Education 

Materials and 

Messages 

Decision 

Aids 

Group 

Education 

One-on-one 

Interactions 

Reducing 

Structural 

Barriers 

Basch et al., 2006180 • 

Braun, et al., 2005184 • 

Campbell, et al., 2004185 • • 

Church et al., 2004183 • • 

Costanza et al., 2007176 • 

Denberg et al., 2006182 • 

Dolan et al., 2002181 • 

Myers et al., 2007175 • • • 

Pignone et al., 2000177 • 

Potter, et al., 2009187 • 

Ruffin et al., 2007178 • 

Sequist, et al., 2009186 • 

Stokamer et al., 200485 • • 

Tu et al., 2006179 • • 

Zapka et al., 2004174 • 

education materials. They are not educational media campaigns that would be provided through 

television advertisements and public service announcements (PSAs); neither are they national 

media campaigns such as the one conducted by the Centers for Disease Control and Prevention 

(CDC) called “Screen for Life,” which uses PSAs on national TV stations to educate people 

about the need for cancer screening tests. Both the small media method of educating the public, 

as well as the large media campaigns, can be used to inform and motivate people to be screened 

for cancer and can be tailored to specific individuals or target general audiences. 

We included in this category the three studies that tested aids in helping patients to make 

informed decisions (i.e., decision aids). Decision aids are mechanisms or interventions that have 

been developed to improve communication between health professionals and patients; their goal 

is to help involve patients in making decisions regarding their health care. Decision aids can 

include brochures, videotapes, or interactive computer programs. 

Group education interventions are those conducted within a specified group setting and 

deliver information or motivation to encourage screening. Although these interventions often 

include handing out information or materials, we categorized studies that included this 

intervention as group education because they also provided a setting in which an individual was 

present to interact with the audience. 

One-on-one education includes studies in which a provider (e.g., physician, nurse, health 

educator) works individually with patients to educate them about CRC screening and/or aid them 

in making decisions about which tests to complete and when to receive screening. These 

interventions tend to include some concentrated time with a patient to answer questions, address 

concerns, and help facilitate completion of screening tests. Studies included in this category 

provided this one-on-one education either by telephone180 or in person.85,179 

The final category includes studies that address reducing or eliminating structural barriers to 

screening. Many problems can make it difficult for people to seek screening for cancer. Barriers 

can include distance from screening location, limited hours of operation, no day care for 

children, limited access to screening tests, and language and cultural factors. These types of 

113 
interventions seek to increase screening by removing structural barriers. In this category, we 

included studies that tested the provision of FOBT tests through the mail, either alone183 or in 

combination with an intervention that also addressed language and cultural barriers that may be 

barriers to screening among Japanese Americans.179 

Overview of results. A total of 15 articles examined the impact of various interventions 

targeting the patient in an attempt to increase CRC screening.85,174-187 All 15 focused on 

screening, not followup. All studies also partially addressed the “appropriate” use of screening 

by using the criteria for screening guidelines as “inclusion” or “exclusion” criteria (e.g., no 

FOBT in prior 12 months, no prior CRC diagnosis) in the sample. Seven studies174-179,187 had an 

upper age limit (from 70 to 79 years) for their studies; eight did not.85,180-186 This feature raises 

the issue of potentially inappropriate screening for older people. Three studies relied only on 

self-reported frequency of CRC screening,178,183,185 which has been shown to overestimate 

screening rates. 

Among these studies, four presented findings of an intervention to provide patient reminders, 

seven focused on the use of small media (e.g., video, letters) to educate patients about the need 

for screening and/or types of tests available or to help their decisionmaking process, two 

presented findings from group education interventions, and three focused on interventions that 

provided one-on-one interactions either by phone on in person to increase screening. 

Five studies addressed barriers to screening by providing FOBTs to patients (i.e., by mail or 

in health clinics) who were due for screening. One of these implemented an intervention that also 

addressed cultural and language barriers.179 

The impact of these interventions on CRC screening rates ranged from 0 percent to 41.9 

percent when the intervention groups were compared with the control groups. Studies that 

examined the use of educational materials presented via small media174-176,185 had no impact on 

screening rates (increase of 0 - 15.1 percentage point change [P = 0.08 for study with highest 

percentage change]); those that provided means for eliminating structural barriers, such as access 

to CRC screening tests or language barriers,85,175,179,183,187 demonstrated the highest impact on 

screening rates overall (14.6 to 41.9 percentage point change). Those that used decision aids 

delivered to patients through small media had mixed results; two studies demonstrated an overall 

increase in CRC screening (14.2 to 23 percentage point change)177-178 and the other demonstrated 

only a 3 percentage point increase in CRC screening.181 Interventions that provided patient 

reminders in the mail or over the telephone had an impact on screening using any CRC test 

ranging from 5.4 percent to 11.7 percent and 15 percent.175,182-183,186 Two studies tested an 

education intervention in a group setting and found no difference in screening rates among their 

samples.184-185 Only one study measured increases in discussions between the patient and 

providers as an outcome of their intervention, reporting a 25.1 percent increase in discussions 

among patients in the intervention group compared with those in the control group.177 

Patient reminders. Study characteristics. Four RCTs, one rated as good quality186 and three 

rated as fair quality, 175,182-183 focused on testing reminders mailed to patients due for screening 

(Table 35). One study used usual care as a comparator; it involved a mailed reminder (brochure) 

sent to patients who had been referred for a screening colonoscopy after an appointment at a 

primary care practice.182 Another study randomized subjects into one of four groups:175 one 

group received a mailed standard intervention (Group 1: SI) that included an informational 

booklet and FOBT kit; a second group received a tailored intervention (Group 2: TI) that 

included the SI package plus tailored “message pages” of brief messages that addressed personal 

barriers to screening; a third group (Group 3: TIP) included the TI package plus a reminder 

telephone call; and the fourth was a control group. All three intervention groups received either a 

letter or a telephone call as a reminder to complete the FOBT. The intervention groups then 

114 
varied on the type of additional education materials they received or the type of contact that was 

made, such that G3 is the only group that received phone calls. These three groups were 

compared with a sample of patients who received usual care. 

Table 35. Studies of patient reminders on increasing colorectal cancer screening rates 

Author, Year 

Study Design 

Population 

Setting 

Sample Size 

Quality Study Aims Study Groups Results (95% CI) 

Sequist et al., 

2009186 

RCT, 15-month 

followup 

11 Ambulatory Health 

Care Centers in 

Massachusetts 

N= 110 physicians, 

21,860 patients 

Good 

Church et al., 2004183 

RCT, 1 year 

Residents, 50 years 

of age or older, of 

Wright County, 

Minnesota 

N = 1,255 

Fair 

Compare the 

individual and 

joint impact of 

personalized 

mailings to 

patients and 

electronic 

reminders to 

primary care 

physicians to 

promote 

colorectal cancer 

screening within 

a multisite group 

practice 

Test direct 

mailing of FOBT 

kits with and 

without 

reminders to 

general 

population 

G1: Patients were mailed a 

package to remind them of need 

for CRC screening that included 

a FOBT kit, letter and pamphlet, 

and a telephone number they 

could call to make an 

appointment for endoscopy 

(n=10,930) 

G2: Usual care for patients 

(n=10,930) 

G3: Providers were given 

electronic reminders during 

office visits that patients were 

overdue for screening (n=55 or 

10,912 patients) 

G4: Usual care such that 

providers received no reminders 

(n=55 or 10,948) 

G1: (no reminders) 

Questionnaire mailed plus 

FOBT kit and instructional 

brochure (n = 434) 

G2: (reminders) Same package 

as G1, plus telephone reminders 

(n = 404) 

G3: Questionnaire only 

(n = 417) 

G1: 25.4% FOBT completion; 44% 

completed any CRC test 

G2: 20.4% FOBT completion (P < 0.001); 

38.1% completed any CRC test (P< 

0.001) 

G3: 41.9% completed any CRC test 

G4: 40.2% completed any CRC test 

(P=0.47) 

Interaction effect between the patient and 

provider interventions was small and not 

statistically significant (-0.6%; 95% CI, ­

1.2%- 0.1%; P = 0.08) 

G1: 16.9% FOBT completion rate (95% 

CI, 11.5-22.3%); 13.2% for any CRC test 

(95% CI, 8.4-18.2%) 

G2: 23.2% FOBT completion rate (95% 

CI, 17.2-29.3%); 14.1% for any CRC test 

(95% CI, 9.1-19.1%) 

G3: 1.5% FOBT completion rate (95% CI, 

-2.9-5.9%); 7.8% for any CRC test (95% 

CI, 3.2-12.0%) 

Denberg et al., 

2006182 

RCT, 4 months 

Primary care 

practices is there a 

city/state? 

N = 781 

Fair 

Test whether a 

mailed brochure 

after referral for 

screening 

colonoscopy will 

increase 

colonoscopy 

completion 

G1: Follow-up mailing of 

educational brochure within 10 

days after a primary care visit 

where a screening colonoscopy 

was recommended (n = 386) 

G2: Usual care (n = 395) 

G1: 70.7% colonoscopy completion rate 

G2: 59% colonoscopy completion rate 

(11.7 percent point difference; 95% CI, 

5.1-18.4%; P = 0.001) 

115 
Table 35. Studies of patient reminders on increasing colorectal cancer screening rates (continued) 

Author, Year 

Study Design 

Population 

Setting 

Sample Size 

Quality Study Aims Study Groups Results (95% CI) 

Myers et al., 2007175 Test whether G1: “Standard Intervention” (SI) G1: 46% completion rate for any test 

targeted and of mailed letter, information (AOR, 1.7; 95% CI, 1.2-2.5) 

RCT, 2 years tailored booklet, FOBT kit, and reminder G2: 44% (AOR, 1.6; 95% CI, 1.2-2.1) 

message letter (n = 387) G3: 48% (AOR, 1.9; 9.5% CI, 1.4-2.6) 

Primary practice delivery, both by G2: Standard intervention G4: 33% 

patients in mail and via package plus 2 “tailored 

Philadelphia, phone outreach, message pages” (TI) (n=386) (P NR) 

Pennsylvania will improve G3: SI plus TI, and a reminder 

CRC screening phone call (TIP) by an educator 

N = 1,546 rates (n=386) 

G4: (control) Usual care 

Fair (n = 387) 

CI, confidence interval; CRC, colorectal cancer; FOBT, fecal occult blood test; G, group; N, sample size; NR, not reported; AOR, adjusted odds 

ratio; P, significance/probability of finding; RCT, randomized controlled trial. 

Another study mailed packages of a letter, pamphlet, and FOBT kit to patients of an 

ambulatory health care center who were due for CRC screening and compared these patients 

with others who received usual care.186 The fourth study randomized residents in a local 

community to mailed FOBT kits without reminders (G1), mailed FOBT kits with telephone 

reminders (G2), or a questionnaire about CRC (G3: control group).183 Because both G1 and G2 

of this study provided mailed FOBT kits to a random sample of local residents, the differences 

between these two groups reflects the impact from telephone reminders to complete the FOBT. 

Three studies focused on patients 50 years of age or older; one study limited its intervention 

to persons 50 to 80 years.186 The times for followup varied: within 4 months of the initial referral 

for colonoscopy screening;182 6 months of the original mailing and 1 year to measure completion 

rates;183 15 months after the initial mailing;186 or 24 months after the initial visit to their 

provider.175 The three studies focusing on populations recruited through a provider setting 

measured their outcomes through medical chart review;175,182,186 the fourth study with a 

randomized sample of residents relied on self-reported screening for their outcomes.183 

Overview of results. All four studies found statistically significant increases in CRC 

screening rates, with absolute increases in screening from about 5.9 percentage points to about 

15 percentage points. The colonoscopy study found an increase in completed colonoscopy from 

59.0 percent in the control group to 70.7 percent in the intervention group (difference: 11.7 

percentage points; 95% CI, 5.1 -18.4 percentage points).182 The tailored intervention study found 

an increase in any CRC screening for all three intervention groups compared with controls (33 

percent control versus 46 percent, 44 percent, and 48 percent; OR, 1.7; 95% CI, 1.3-2.5; OR, 1.6; 

95% CI, 1.2-2.1; OR, 1.9; 95% CI, 1.4-2.6), but no difference among the interventions.175 In the 

TIP group, 28 percent did not receive a telephone call. The study providing FOBT kits to patients 

of ambulatory care centers found that those who received mailings were more likely to obtain 

screening than those who did not (44.0 percent versus 38.1 percent, respectively, P < 0.001).186 

The population-based study that mailed FOBT kits to the intervention groups and followed them 

either with or without reminders reported an increase in completion of any CRC screening of 7.8 

percent (95% CI, 3.2-12.0 percent) for the control group, 13.2 percent (8.4-18.2 percent) for the 

FOBT without reminders group, and 14.1 percent (9.1-19.1 percent) for the FOBT with 

116 
reminders group.183 The difference between FOBT with reminders and controls was statistically 

significant. Overall baseline adherence to any CRC screening was 55.8 percent; the final 

adherence rate for any CRC screening was above 60 percent for the intervention groups, 

although these rates were self-reported. The primary care and population-based studies showed 

little increase in screening with increased intensity of intervention.175,183 

Detailed results. The one study using only mailed patient reminders provided a brochure 

about CRC tests for patients who had been referred for a screening colonoscopy.182 Patients in 

the intervention group were mailed the information brochure within 10 days of referral for the 

colonoscopy. Each brochure included the primary care physician’s name, encouraged patients to 

schedule the procedure, and explained CRC and polyps, the risks of being diagnosed with CRC, 

the nature of bowel preparation, alternative screening tests, and the complication risks of 

colonoscopy. Those patients assigned to the control group had been referred for screening 

colonoscopy as well but received no reminder. The findings indicated that patients receiving the 

reminders were more likely to complete the test (within the 4-month follow-up period) than those 

who did not (11.7 percentage point difference; 95% CI, 5.1-18.4 percentage points; P = 0.001). 

The second study examined three different types of interventions, all with varying intensity, 

and compared them with a control group that received usual care and none of the study 

intervention contacts.175 In the standard intervention (G1), patients were mailed a package that 

included a CRC screening invitation letter, information booklet, FOBT kit, and reminder letter. 

The package also included instructions for completing a home FOBT and on arranging for a 

flexible sigmoidoscopy (FS). The TI patients (G2) received the SI package and two tailored 

message pages, which addressed personal barriers to FOBT and FS that were identified through 

analysis of baseline survey data collection. TIP patients (G3) received the SI and TI information 

and a telephone reminder to conduct the FOBT. During these telephone calls, a trained health 

educator reviewed the mailed materials and encouraged participants to consider screening. 

Although the investigators did find that groups that received some form of reminder were more 

likely to complete screening than those who received usual care (P = 0.001 or 0.002), they did 

not find differences among the intervention groups to indicate whether patients who received 

mail or telephone reminders (SI: AOR, 1.7; 95% CI, 1.3-2.5; TI: AOR, 1.6; 95% CI, 1.2-2.1), or 

a combination of the two (TIP: OR, 1.9; 95% CI, 1.4-2.6) were any more likely than any other to 

be screened. 

The third study conducted in a clinic setting identified patients through their medical record 

system who were overdue for CRC screening (N = 21,860).186 Patients ages 50 to 80 years were 

randomly selected to receive a package that included (1) a letter from the chief medical officer 

explaining that the patient is overdue for screening; (2) an educational pamphlet explaining the 

screening test options; (3) FOBT kit with instructions; and (4) a telephone line dedicated to 

having patients call to make endoscopy appointments. A second mailing was sent to 

nonrespondents at 6 months. Patients who received the mailing were more likely than the control 

group to complete a FOBT (25.4 percent versus 20.4 percent, respectively; P < 0.001) or any 

CRC test (44.0 percent versus 39.1 percent, respectively; P < 0.001). 

The fourth study tested receipt of reminders versus no reminders and compared both with a 

control group.183 The study identified a random sample of residents in Wright County, 

Minnesota, who were determined to be 50 years of age or older based on records from the 

Minnesota State Driver’s License and Identification Card database. The sample was divided into 

three groups: the control group (Group 3) and two intervention groups that both received 

informational packages but differed in terms of whether they received telephone reminders for 

testing (Group 2) or not (Group 1). All three groups were mailed an initial survey on CRC and 

then either received no additional information until the follow-up survey in 1 year (Group 3) or 

117 
received a package of information approximately 2 months after the questionnaire that included 

an FOBT kit with instructions and educational material about CRC and screening test. Group 2 

individual who did not return FOBT kits were mailed reminder letters 1 month later that included 

another FOBT kit and then, if they had still not returned an FOBT, they received a telephone call 

1 month later. Of those in the “no reminder” group (Group 1), 49.6 percent of the participants 

accidentally received the first reminder letter with no further contact. They did not receive any of 

the subsequent reminders (i.e., two more mailings and telephone calls). The authors did not 

report the number of respondents in Group 2 who had been called Although the study did report 

self-reported completion of any CRC test, the findings specific to reminders demonstrated an 

overall increase of 6.3 percent in completion of FOBT for Group 2 received telephone reminders 

(received reminders: 23.2 percent FOBT completion rate; 95% CI, 17.2-29.3 percent) and Group 

2 (no reminders: 16.9 percent FOBT completion rate; 95% CI, 11.5-22.3 percent). 

Small media interventions. Seven RCTs were patient-directed small media interventions; 

that is, these studies that used various tools such as print materials or telephone calls to provide 

education to a targeted sample. We divided this set of studies into two categories: (1) four studies 

that focused on small media interventions that were not decision aids174-176,185 and (2) three 

studies of decision aids.177-178,181 

Small media: educational materials and messages. Study characteristics. As shown in 

Table 36, one study in this category was rated as good quality174 and three were rated as fair 

quality.175-176,185 The populations targeted for all four studies were at average risk for CRC and 

met recommendations for screening tests. All four studies focused on those 50 years or older.174­

176,185 The populations in three studies were recruited from primary care practices, and patients in 

each of the control groups were receiving usual care. Because these were patients already 

receiving care from a physician, “usual care” was defined as people who received none of the 

interventions.175-176 The fourth study recruited church members from predominantly AfricanAmerican churches located in rural areas of one state and compared their intervention with those 

in churches whose members received education on unrelated health topics.185 Participants of two 

of the studies were predominantly non-Hispanic white;174,176 the third primary care study 

included 39 percent multiracial (race unspecified) participants from an urban center,175 and the 

fourth study included only African Americans.185 Two interventions focused on mailing 

educational materials, followed by telephone contact;175-176 the third intervention consisted of a 

mailed 15-minute videotape,174 and the fourth intervention included a combination of print and 

video materials that were mailed at 2-month intervals over the 9-month intervention period.185 

The timing for measuring outcomes ranged from 6 months174 to 24 months.175 Three studies 

measured their outcome of receiving any CRC test by reviewing medical charts;174-176 the fourth 

measured CRC screening through self-reported responses.185 

Overview of results. The four studies that did not deal with decision aids demonstrated 

consistent findings with regard to education materials and information provided to patients via 

small media: such interventions had no influence on CRC screening rates that was found to be 

statistically significant (0 percent to 15.1 percentage point differences in rates among 

intervention and control groups across studies). 

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Table 36. Studies of small media: Educational materials and messages on increasing colorectal cancer 

screening rates 

Author, Year 

Study Design 

Population 

Setting 

Sample Size 

Quality Study Aims Study Groups Results 

Zapka et al., 2004174 

RCT, 6 months 

Primary care practices in 

central Massachusetts 

N = 938 

Good 

Campbell et al., 2004185 

RCT, 1 year follow-up 

African-American churches 

in rural North Carolina 

N = 287 (50 years or older) 

Fair 

Costanza et al., 2007176 

RCT, 17-22 months 

Primary care practice in 

Massachusetts 

N = 2,448 

Fair 

Myers, et al., 2007175 

RCT, 2 years 

Primary practice patients in 

Philadelphia, Pennsylvania 

N = 1,546 

Fair 

Test the effect on 

CRC screening of 

an educational 

video mailed to 

patients’ homes 

before a physical 

examination 

To test an 

intervention to 

improve multiple 

health behaviors 

among rural 

African American 

church members 

Test stage-based 

computerassisted tailored 

telephone 

counseling to 

promote CRC 

screening in a 

primary care 

population. 

Test targeted and 

tailored message 

delivery, both by 

mail and via 

phone outreach 

G1: Patients scheduled for an 

upcoming physical examination 

received a video in the mail prior to 

appointment (n = 450) 

G2: Usual care (n = 488) 

G1: TPV materials distributed to 

church members via mail (n= 76) 

G2: LHA trained within 

experimental churches to provide 

CRC information through existing 

networks (n=51) 

G3: Combination of TPV and LHA 

(n=87) 

G4: Speakers came to churches 

and offered educational workshops 

on a variety of topics (e.g., 

HIV/AID); provided members 

education materials (n=69) 

G1: Mailed brochure followed by 

computer-assisted stage-based 

telephone counseling (n = 1,187) 

G2: Usual care (n = 1,261) 

G1: “Standard Intervention” (SI) of 

mailed letter, information booklet, 

FOBT kit, and reminder letter 

(n = 387) 

G2: Standard intervention package 

plus 2 “tailored message pages” 

(TI) 

G3: SI plus TI, and a reminder
 

phone call (TIP) by an educator 

G4: (control) Usual care (n = 387) 

G1: 55% overall screening rate 

G2: 55% screening rate 

G1: 36.8% received FOBT test; 

21.1% received another CRC 

test 

G2: 33.3% received FOBT test; 

25.5% received another CRC 

test 

G3: 31.0% received FOBT test; 

14.9% received another CRC 

test 

G4: 21.7% received FOBT test; 

27.5% received another CRC 

test 

Differences in group are not 

statistically significant (p=0.08 

for FOBT, NR for ‘other’ tests; 

only ‘ns’ noted). 

G1: 25% completed any CRC 

test 

G2: 24% completed any CRC 

test (P = 0.68) 

G1: 46% screening rate (AOR, 

1.7; 95% CI, 1.2-2.5) 

G2: 44% (AOR, 1.6; 95% CI, 1.2­

2.1) 

G3: 48% (AOR, 1.9; 95% CI, 1.4­

2.6) 

G4: 33% 

(P NR) 

AOR, adjusted odds ratio; CI, confidence interval; CRC, colorectal cancer; FOBT, fecal occult blood test; G, group; HIV/AIDs, human 

immunodeficiency virus/acquired immune deficiency syndrome LHA, lay health advisor; FOBT, fecal occult blood test; N, sample size; NR, not 

reported; ns, not significant; RCT, randomized controlled trial; SI, standard intervention; TI, tailored intervention; TPV, tailored print and video. 

119 
For one study, determining the increase in screening specific to the educational materials was 

somewhat challenging.175 It included multiple strategies; the primary difference between the 

control group and the three intervention groups was that all the intervention groups received both 

an FOBT kit and some type of reminder to complete the test (either by letter or by letter and 

telephone). The differences between the three intervention groups are in the type of small media 

used to influence completion of CRC testing. These three groups did not differ in terms of 

completion of CRC screening for patients who received print material only compared with those 

who got print materials plus telephone reminders (2 percentage point difference in screening 

rates).175 

The other two studies also had no effect on screening rates (0-1 percentage point difference 

in control and intervention groups).174,176 

Detailed results. One good-quality study explored the effect of mailing an educational video 

to patients’ homes just before they had an appointment for a physical examination.174 The 

research team mailed a letter to potential participants who were 50 to 74 years of age and had an 

appointment with their primary care provider in the next 3 weeks. After conducting a baseline 

interview with all interested patients, they randomly assigned patients to receive an educational 

video through the mail or to usual care (i.e., no video). The 15-minute video included 

information to encourage discussion with their provider about CRC screening and increase the 

use of screening, particularly by FS. The mailed package with the video also included a letter 

encouraging the patient to view the video. After the video was mailed, the patients were 

interviewed by telephone between 4 and 6 months after the primary care appointment to 

determine whether they had obtained screening. This study reported no difference in screening 

rates among the intervention and control group participants (55 percent for both groups). 

Another study involved rural churches in North Carolina with high proportions of AfricanAmerican members.185 The study aims included improving nutrition and physical activity, but 

those participating who were age 50 years or older were also encouraged to obtain CRC 

screening. The intervention included two components: a tailored communication to select church 

members randomly and another that involved group education provided by a lay health advisor. 

We categorized this study into both small media and group education interventions. 

For the small media component of the intervention, individual computerized materials were 

developed based on information obtained through a baseline survey administered to all 

participants. The tailored package of information included newsletters along with four targeted 

videotapes mailed to participants’ homes. These packages were mailed bi-monthly during 

months 2, 4, and 6 of the intervention; the fourth mailing occurred during month 9. The 

videotapes included testimonials from community members and pastors on each of the targeted 

behaviors of the intervention. Participants in this group were compared with those attending 

churches in the control group, each of which were offered health education sessions and speakers 

on topics of their choice not directly related to the study objectives. The second component of 

group education by lay health educators is described under that intervention type. Members of 

control churches were no more likely to obtain CRC screening than those who received tailored 

education (P = 0.08). 

A fair-quality study used telephone counseling to attempt to increase CRC screening; the 

investigators initiated contact with patients by first mailing a baseline survey to potential 

participants who were active patients of primary care practices (i.e., documented visit in the prior 

2 years).176 Upon receiving the baseline survey from patients, the investigators randomized 

respondents to the control group to receive usual care or to the intervention group. For the 

intervention group, the researchers mailed a print brochure 2 months after receipt of the baseline 

survey; it provided basic CRC information and screening. Three months after receiving their 

120 
brochure, participants received tailored computer-assisted telephone counseling; for this, a 

computer generated an interview protocol based on patients’ initial responses about their 

knowledge of CRC and screening tests. Trained interviewers administered the protocol to 

provide basic education (approximately 4 minutes) and motivational counseling (approximately 

6 minutes) to obtain screening. Approximately 17 to 24 months after receipt of the telephone 

counseling, the investigators reviewed participants’ charts to determine whether CRC tests had 

been completed. This study found no difference in overall screening rates between the 

intervention and control groups (25 percent versus 24 percent; P = 0.68). 

Although the third study, described previously under patient reminders, found that groups 

that received some form of reminder were more likely to complete screening than those who 

received usual care (P = 0.001 or 0.002), the researchers did not find differences among the 

intervention groups to indicate whether patients who receive various types of small media 

interventions (i.e., print or telephone) were more (or less) likely to complete CRC screening. 

Small media: decision aids. Study characteristics. As shown in Table 37, three RCTs, one 

rated as good quality178 and the other two as fair,177,181 used decision aids to help patients make 

informed decisions about CRC testing and the type of test to request. All three studies focused on 

patients 50 years of age or older; they either were attending appointments at an internal medicine 

practice181 or a primary care practice177 or were selected through a random sample of local 

residents living in urban, suburban, or rural communities.178 

One primary care study compared an intervention group viewing an 11-minute CRC 

screening video decision aid followed by a brochure for the patient and a colored chart marker 

for the physician with a control group viewing an automobile safety video with no colored chart 

marker placed in the record.177 The other primary care study randomized participants to either an 

interviewer-administered printed decision aid (modeled on the analytic hierarchy process) or to 

printed CRC screening educational materials.181 The third study, which included only 

participants familiar with computers, compared a computerized, interactive decision aid with a 

standard informational, noninteractive website concerning CRC.178 

All three studies had control groups comprising patients who got some type of exposure to a 

CRC-related website,178 to an unrelated topic,177 or to basic information about CRC.181 Two of 

the three studies had comparison or control groups that received some form of CRC 

education.178,181 Time to followup among the studies ranged from 2 to 3 months177,181 to 24 

weeks.178 Two studies assessed the outcome of completed screening of any test through medical 

chart review;177,181 the third used follow-up telephone interviews.178 

Overview of results. Results from the three decision aids studies are mixed. One study 

demonstrated a statistically significant increase in CRC test completion178 (23 percent difference; 

OR, 3.23; 95% CI, 2.73-3.50; P = 0.035). Another showed an increase in completion of CRC 

testing in the intervention group compared with the control group (14.2 percentage point 

difference; 95% CI, 3.0-25.4 percentage points).177 This same study demonstrated that a higher 

proportion of patients in the intervention group than the control group reported discussing CRC 

screening with their provider during their appointment (68.5 percent and 43.4 percent, 

respectively; 25.1 percentage point difference; 95% CI, 12.7-37.6 percentage points). By 

contrast, the third study reported no significant difference in CRC test completion between the 

intervention and control groups.181 

121 
Table 37. Studies of small media: Decision aids on increasing colorectal cancer screening rates 

Author, Year 

Study Design 

Population 

Setting 

Sample Size 

Quality 

Ruffin et al., 2007178 

Study Aims 

Test interactive 

Study Groups 

G1: Participants completed 

Results 

G1: 56% completed any CRC test 

website, baseline assessments and (23 percentage point difference; 

RCT, 24 weeks Colorectal Web, to then were given a laptop to AOR, 3.23; 95% CI, 2.73-3.50; 

aid in decision- access interactive website, P = 0.035) 

Residents in Michigan making of types of with posttest then G2: 33% completed any CRC test 

test to complete administered (n = 87) 

N = 174 G2: Same as G1 except asked 

to access a standard, 

Good noninteractive format website 

(n = 87) 

Dolan and Frisina, 2002181 Test a decision G1: Detailed written materials G1: 49% completed any CRC 

aid designed to given to patients to explain the screening 

RCT, 2 to 3 months help patients different CRC screening G2: 52% completed any CRC 

choose among options (n = 49) screening (P = 1.0) 

Internal medicine practice currently G2: standardized interview 

in New York recommended consisting of a brief description 

CRC tests of CRC (n = 46) 

N = 95 

Fair 

Pignone et al., 2000177 Test whether a G1: Video about CRC G1: 68.5% reported conversations 

decision aid screening options, and a with provider about CRC screening; 

RCT, 3 months consisting of an brochure about CRC 36.8% completed any CRC test 

educational video, screening (n = 125) G2: 43.4% reported conversations 

Three community primary targeted brochure, G2 (control): Video about (25.1 percentage point difference; 

care providers in North and chart marker traffic safety (n = 124) 95% CI, 12.7-37.6%); 22.6% 

Carolina increased CRC completed any CRC test (14.2 

screening percentage point difference; 95% 

N = 249 CI, 3.0-25.4%) 

Fair (P NR) 

AOR, adjusted odds ratio; CI, confidence interval; CRC, colorectal cancer; FOBT, fecal occult blood test; G, group; N, sample size; NR, not 

reported; RCT, randomized controlled trial. 

Detailed results. The good-quality study obtained a random sample of residents 50 years of 

age or older who live in urban, suburban, or rural communities in Michigan.178 The investigators 

first contacted potential participants by telephone and screened for their computer knowledge to 

ensure that participants could adequately search the websites in the study and meet other 

eligibility criteria. Participants were then scheduled for an appointment at a local community site 

for review of the websites. Participants were randomly assigned to view and explore one of two 

sites: (1) an interactive password-protected website, Colorectal Web (http://colorectalweb.org), 

which was designed to aid in their decision of types of CRC tests to obtain or (2) a standard, 

noninteractive informational website (control group) with similar content as the intervention 

website. During the computer sessions, participants were asked to review as much of the website 

as they desired. At the end of the session, participants completed a questionnaire specific to their 

preference for testing and decision phase of choosing to get screening. All participants were 

interviewed by telephone 2, 8, and 24 weeks after review of the websites to determine their 

intention to get screened and whether they had received any CRC test. Participants in the 

intervention group were more likely to have completed any CRC test within 24 weeks (56 

percent) than the control group (33 percent) (AOR, 3.23; 95% CI, 2.73-3.50; P = 0.035). 

122 
The remaining two studies, rated fair quality, also tested different types of small media in 

aiding patient decisionmaking.177,181 One study provided written materials to patients assigned to 

the intervention arm who were at an appointment at an internal medicine practice in New 

York.181 Within a few days before a scheduled appointment with a provider, the consenting 

patients in the intervention group received short descriptions of CRC and the five types of 

screening tests available to them and completed a baseline survey. Trained interviewers also 

guided this group through an analytic hierarchy process specifically designed to help them make 

decisions that require integration of quantitative data with less tangible, qualitative 

considerations such as values and preferences. The control group was first interviewed face-toface at the time of their appointment where the interviewer provided them with a brief 

description of CRC and asked them to complete the same survey as the intervention group. All 

patients were then urged to discuss CRC screening with their provider. After their visit, all 

patients were asked whether they discussed the screening with their provider and whether a 

decision had been made. A majority of all patients (88 total or 93 percent) indicated that they had 

discussed CRC screening with their provider, but the intervention group was no more likely than 

the control group to have completed any CRC test. 

The study testing whether a video decision aid given to patients at the time of a primary care 

appointment in North Carolina would increase screening rates reported similar findings.177 Three 

primary care practices with a total of nine physicians agreed to participate in the study. For study 

recruitment, patients were contacted by phone before a scheduled appointment and asked to 

participate. The intervention group for this study was asked to watch an 11-minute video on CRC 

that included information about susceptibility to CRC and availability of screening tests, 

specifically the FOBT and FS. The video included vignettes of patients who discussed their 

experiences with CRC screening. At the conclusion of the video, the patients were asked about 

their intent to request screening and then provided one of three color-coded brochures that were 

designed to provide information based on a person’s intention to obtain screening. The 

researchers placed a laminated card with the same color as a patient’s brochure in the patient’s 

chart before he or she was seen by the provider. Patients in the controls watched a video of 

similar length on car safety and received a related brochure. No cards were attached to their 

charts. During the appointment, patients were asked to complete three surveys: one at baseline 

before seeing a video; one after viewing the video; and one after seeing the provider to assess 

whether a conversation about CRC occurred. The investigators completed medical record 

reviews within 3 months of the visits to determine whether CRC tests had been completed. The 

outcome reported related to discussions was whether a test was ordered. In the intervention 

group, 68.5 percent of patients and 43.4 percent of control group patients reported some 

conversation with their provider about CRC screening (25.1 percentage point difference; 95% 

CI, 12.7-37.6 percentage points). Screening tests were completed by 36.8 percent in the 

intervention group and 22.6 percent of the control group (14.2 percentage point difference; 95% 

CI, 3.0-25.4 percentage points). 

Group education interventions. Study characteristics. Two RCTs tested an intervention to 

educate Native Hawaiians who are members in local civic clubs about the importance of CRC 

screening184 or were trained to educate their fellow church members in rural predominantly 

African-American churches185 (Table 38). In one study, civic clubs were randomly selected for 

the intervention and either a Native Hawaiian physician and cancer survivor or a non-Native 

123 
Table 38. Studies of group education on increasing CRC screening rates 

Author, Year 

Study Design 

Population 

Setting 

Sample Size 

Quality 

Braun et al., 2005184 

Study Aims 

Test an 

Study Groups 

G1: Educational workshop 

Results 

G1: 23 (33%) completed FOBT (41 

intervention to delivered by Native Hawaiian were already up-to-date for CRC 

RCT, 16 week follow-up improve CRC physician and cancer survivor, screening at baseline so n=28 

screening among FOBT kits provided, and eligible for screening) 

Civic clubs in Hawaii Native Hawaiians follow-up reminder calls to G2: 21 (40%) completed FOBT (36 

submit test (n=69) were up-to-date at baseline so n=16 

N=121 G2: Educational workshop by eligible to screen which means more 

non-Native Hawaiian nurse, were screened than needed to be) 

Fair FOBT test, 1 reminder call to 

submit test (n=52) People in G1 were less likely to be 

screened than people in control 

group (AOR, 0.36; 95% CI, 0.14- 

Campbell et al., 2004185 Test an G1: TPV materials distributed 

0.97) 

G1: 36.8% received FOBT test; 

intervention to to church members via mail 21.1% received another CRC test 

RCT, 1 year follow-up improve multiple (n= 76) G2: 33.3% received FOBT test; 

health behaviors G2: LHA trained within 25.5% received another CRC test 

African American among rural experimental churches to G3: 31.0% received FOBT test; 

churches in rural North African American provide CRC information 14.9% received another CRC test 

Carolina church members through existing networks G4: 21.7% received FOBT test; 

(n=51) 27.5% received another CRC test 

N= 287 (50 years or older) G3: Combination of TPV and 

LHA (n=87) Differences in group are not 

Fair G4: Speakers came to statistically significant (p=0.08 for 

churches and offered FOBT). 

educational workshops on a 

variety of topics (e.g., 

HIV/AID); provided members 

education materials (n=69) 

AOR, adjusted odds ratio; CI, confidence interval; CRC, colorectal cancer; FOBT, fecal occult blood test; LHA, lay health advisor; G, group; N, 

sample size; NR, not reported; RCT, randomized controlled trial; TPV, tailored print and video. 

Hawaiian nurse provided an education session on the need for screening and provided 

participants with FOBT kits.184 Any participants ages 50 or older were included in the 

intervention. The study followed participants over a 16-week period and used reports from the 

laboratory that received completed FOBTs to determine whether they had completed a FOBT kit. 

The second study targeted African-American churches in rural North Carolina with the aim of 

improving nutrition, exercise, and CRC screening.185 Any church members within an 

intervention site could participate, but only those 50 years or older were targeted for CRC 

screening. The group education consisted of training volunteers to serve as lay health advisors, 

who then agreed to conduct group education sessions within their church over the 1-year study 

period. Outcomes for both studies were assessed through self-reported screening rates, with both 

focusing on FOBT completion rates as their primary outcome. 

Overview of results. One study demonstrated a negative finding: those in the control group 

were statistically significant more likely to have completed a FOBT over the 16-week study 

period than those in the intervention group (AOR, 0.36; 95% CI, 0.14-0.97).184 The second study 

found no difference between those who received group education and those in control churches 

(P = 0.08).185 

124 
Detailed results. The study based in Hawaii involved members of local civic clubs who were 

provided with an educational session specific to CRC screening at one of their regularly 

scheduled meetings.184 The control group received the education from a non-Native nurse who 

addressed topics specific to CRC screening and the importance of screening among Native 

Hawaiians. She then distributed a FOBT kit along with basic instructions on completing the test, 

and a phone number of local providers they could contact for assistance. Within a month of the 

presentation, if a completed FOBT kit had not been received from participants, one reminder call 

was made to each and a replacement FOBT kit was mailed upon request. The intervention group 

differed in that the presenter at the workshop included a physician and survivor who were both 

Native Hawaiian. Participants in this group were also provided a FOBT and a demonstration on 

how to complete the test was also presented by the physician. Between 4 and 16 weeks after the 

presentation, multiple telephone calls were made to those who had not completed the FOBT kit 

and replacement kits were provided upon request. Information on the frequency and intensity of 

these reminder calls is not provided by the authors so this study is not categorized as one 

providing patient reminders since we were unable to determine the extent to which the control 

and intervention groups differed on this aspect of the intervention. The outcomes for the study 

were determined through copies of the FOBT results received from the laboratory that tested 

them. Overall, the authors reported that people in the intervention group were less likely to 

complete a FOBT than people in the control group (33 percent compared to 40 percent, 

respectively). 

The study based in rural churches in North Carolina included two components of 

interventions, one that involved small media which is described elsewhere and a second that 

included training church members to serve as lay health advisors and conduct group education 

sessions with their peers.185 Church members were asked to recommend people to serve as lay 

health advisors, who were then invited to attend a series of trainings. A total of 62 such advisors 

(47 women, 15 men) from six churches were trained through six sessions. The training included 

information specific to CRC screening, available tests, and a detailed training manual was 

provided to each participant. In addition to providing information to peers through existing social 

networks, the lay health advisors were expected to organize and conduct at least three churchwide activities focused on spreading information about nutrition, exercise, and/or CRC 

screening. Findings indicated that churches where these advisors were present were no more 

likely to have members who received FOBT or any CRC test than control churches. In addition, 

some churches included both tailored or small media education combined with lay advisors, but 

this combination produced no effect compared with a control group. 

One-on-one interactions. Study characteristics. Three RCTs, two rated as good quality179-180 

and the other as fair quality,85 tested one-on-one interactions with patients as a way to increase 

screening rates (Table 39). Interactions involved a nurse who conducted85 a series of telephone 

calls to participants of a health plan,180 and a health educator.179 Two studies were conducted 

within a primary care or community clinic setting and relied on medical chart review for 

screening outcomes;85,179 the third worked with a random sample of participants in a health 

benefit fund.180 Two studies included patients who had not yet agreed to screening;179-180 the 

other involved patients who had agreed to FOBT screening.85 In two studies populations 

included those 50 years of age or older determined to be in need of screening based on national 

guidelines;85,179 the third study focused on those 52 years of age and older who were selfreported as not current on their CRC screening (i.e., no FOBT in past 2 years, no FS in past 5 

years, or no colonoscopy or barium enema in past 10 years).180 All three studies were in urban 

settings; one had about two-thirds African-American participants,180 another had about one- third 

125 
Table 39. Studies of one-on-one interactions on increasing colorectal cancer screening rates 

Author, Year 

Study Design 

Population 

Setting 

Sample Size 

Quality Study Aims Study Groups Results 

Basch et al., 2006180 

RCT, 6 months 

Members of a New 

York health benefit 

fund that includes CRC 

screening coverage 

N = 456 

Good 

Tu et al., 2006179 

RCT, 6 months 

Community clinic in 

Seattle, Washington 

N = 210 

Good 

Stokamer et al., 200485 

RCT, 6 months 

Primary care clinic at a 

VA in NYC 

N = 788 

Fair 

Test the 

effectiveness of a 

telephone 

outreach 

approach versus a 

direct mail 

approach in a 

predominantly 

African-American 

population 

Test a clinicbased, culturally 

and linguistically 

appropriate 

intervention 

promoting FOBT 

screening 

Test whether 

intensive patient 

education 

increases FOBT 

card return rates 

G1: Tailored telephone outreach 

by a health educator through 

repeated calls (median = 5) to 

educate patients on the need for 

screening and build their selfefficacy in obtaining screening 

(n = 226) 

G2: Mailed package that 

included a letter and brochure 

about CRC screening (n = 230) 

G1: Bilingual materials including 

motivational video on CRC 

screening, pamphlet, FOBT 

instruction sheet, CRC 

informational pamphlet, CRC 

screening education from a 

health educator, and FOBT kit 

with instructions in Chinese and 

English (n = 105) 

G2: Usual care (n = 105) 

G1: Educational session of 10 to 

15 minutes with nurse, FOBT kit 

(n = 396) 

G2: Usual care (includes FOBT 

kit) (n = 392) 

G1: 27% received any CRC test 

(n = 61) 

G2: 6.1% (n = 14) 

Rate difference = 20.9 percentage 

points; 95% CI, 14.34-27.46 

RR 4.4 (2.6-7.7) 

(P NR) 

G1: 69.5% received FOBT screening 

G2: 27.6% received FOBT screening 

(AOR, 6.38; 95% CI, 3.44-11.85) 

(P NR) 

G1: 65.9% returned FOBT cards 

G2: 51.3% returned FOBT cards 

(P<0.001) 

AOR, adjusted odds ratio; CI, confidence interval; CRC, colorectal cancer; FOBT, fecal occult blood test; G, group; N, sample size; NR, not 

reported; NYC, New York City; P, significance/probability of finding; RCT, randomized controlled trial; RR, relative risk; VA, veterans 

administration. 

African-American participants,85 and the third comprised almost entirely Chinese participants.179 

The time periods of each study varied: the one involving nurses85 and the one targeting the health 

benefit fund followed patients for 6 months, 180 and the one with a culturally and linguistically 

sensitive health educator spanned a 14-month period from the initial interaction with patients.179 

The two studies based in a clinic included control groups that received usual care,85,179 while the 

control group for the study of health benefit fund participants received print materials in the mail, 

which included a brochure about CRC and available screening tests.180 All three studies relied on 

medical records review for measuring the outcome of completion of CRC screening, with one 

study first collecting self-reported data that was then compared with claims data in the health 

benefit fund database.180 

Overview of results. All studies found statistically significant positive effects of their 

interventions. In the study of patients who had agreed to FOBT screening, 65.9 percent of 

intervention patients and 51.3 percent of the usual care group (P < 0.001) returned the FOBT 

cards; the median time to return the cards was shorter in the intervention group (36 versus 143 

days, P < 0.001).85 In the study of Chinese patients considering CRC screening, 69.5 percent of 

126 
intervention versus 27.6 percent of control patients had completed FOBT screening (AOR, 6.38; 

95% CI, 3.44-11.85).179 The third study, which provided intensive telephone counseling to 

participants of a health benefit fund, also demonstrated statistically significant differences in 

completion of any CRC test (rate difference = 20.9 percentage points; 95% CI, 14.34-27.46 

percentage points).180 

Detailed results. The good-quality study of telephone outreach compared these participants 

to a group of patients who received only a mailed brochure with information about CRC and 

available screening tests.180 The sampling frame for the study included persons 52 years of age or 

older who were members of a health benefit fund that included CRC screening as a benefit. 

Potential participants were first contacted by telephone to assess their interest in the study and 

then randomly assigned to receive telephone education or print education. The control group was 

mailed a letter along with a print brochure that included information about CRC, how it can be 

prevented, and descriptions of screening tests. The participants were instructed to talk with their 

providers to seek screening. The intervention group received tailored telephone outreach that 

began within 2 weeks of randomization. A series of semistructured telephone calls were then 

conducted with the participant to discuss CRC screening and provide positive reinforcement for 

obtaining a screening test. The frequency and duration of calls varied, with a median of 5 calls to 

each participant and a median of 23.5 minutes with each participant. The topics of these calls 

included establishing a trusting rapport with participants, reinforcing accurate knowledge about 

CRC and screening, correcting misconceptions, and bolstering motivation to obtain CRC 

screening. All participants were contacted 6 months after randomization by telephone to obtain 

information about whether they had obtained any CRC screening test (i.e., single office FOBT, 

home FOBT, FS, or colonoscopy). This self-reported information was verified either through 

medical records from each participant’s provider or through the health benefit fund’s billing 

system. Patients who received tailored outreach were more likely to be screened than those that 

received only the mailed brochure (27 percent and 6.1 percent, respectively; RR, 4.4; 95% CI, 

2.6-7.7). 

The study that explored the role of nurses in encouraging completion of FOBT provided 

patients in the intervention arm with 10- to 15-minute educational sessions conducted by a nurse 

specifically trained for this intervention.85 All patients had been referred by their physician to 

primary care nursing for education and distribution of FOBT kits. The intensive session included 

providing patients with a two-page informational handout on FOBT and CRC. The session also 

provided verbal instructions on how to perform an FOBT and explanation of the meaning of 

different results. The nurse answered questions and instructed the patients to return the FOBT 

cards within 2 weeks and/or call with any questions. Patients randomly assigned to the control 

group received usual care, which consisted of receipt of FOBT kit that included written 

instructions and no individual session with a nurse. The outcomes for the study were assessed 

through medical record review 6 months after the patient’s appointment to determine whether the 

patients had returned FOBT cards. The intervention group was more likely to return FOBT cards 

than the control group (65.9 percent and 51.3 percent, respectively, P < 0.001). 

In another study, predominately Chinese patients who had not yet agreed to screening 

attended an intensive education session with health educators who provided culturally and 

linguistically appropriate (78 percent of participants spoke Cantonese and 21 percent spoke 

Mandarin) education about CRC screening, including a motivational video, printed material, and 

FOBT kit.179 Patients were randomly selected for participation through the electronic medical 

database and mailed bilingual letters signed by the medical director of the two participating 

clinics to invite them to participate. The health educator then tracked appointments through the 

clinic electronic scheduling system and met face-to-face with prospective participants during 

127 
their visit. Patients who agreed to participate either received usual care (no CRC information) or 

were asked to meet with the health educator who distributed the educational materials. Those 

patients assigned to the intervention group were able to watch the video at the clinic office or 

take it home. The control group received usual care but the study did not specify whether usual 

care included provision of an FOBT kit with bilingual instructions. The investigators assessed 

return of FOBT cards within 6 months of randomization through electronic medical records; this 

outcome was increased in the intervention group when compared with the control group (69.5 

percent and 27.6 percent, respectively; OR, 6.38; 95% CI, 3.44-11.85). 

Eliminating structural barriers. Study characteristics. This category includes five studies 

(Table 40); two were described under patient reminders;85,175,179,183 two under one-on-one 

interactions;85,175,179,183 and is described here in detail.187 All provided FOBT kits as a means to 

improve access to screening tests. One study also attempted to address cultural and linguistic 

barriers among an Asian population of patients.179 We rated two studies as good quality179,187 and 

others as fair.85,175,183 All five studies included people 50 years of age or older in their samples; 

one study specified an upper range of 79 years for study participants.187 

Table 40. Studies of interventions to eliminate structural barriers on increasing colorectal cancer screening 

rates 

Author, Year 

Study Design 

Population 

Setting 

Sample Size 

Quality Study Aims Study Groups Results 

Potter et al., 2009187 

RCT, 6 month follow-up 

Family health center in San 

Francisco, California 

N= 514 

Good 

Tu et al., 2006179 

RCT, 6 months 

Community clinic in 

Seattle, Washington 

N = 210 

Good 

Determine whether 

providing FOBT kits 

during influenza 

season can 

contribute to higher 

CRC screening 

rates. 

Test a clinic-based, 

culturally and 

linguistically 

appropriate 

intervention 

promoting FOBT 

screening 

All patients were mailed multilingual flu shot information 

G1: Patients received a FOBT kit 

and instruction sheet at the time 

they obtained a flu shot (n=268; 

only 143 received FOBT kit since 

rest were ineligible due to being 

up-to-date for screening) 

G2: Patient received flu shot only 

(n=246) 

G1: Bilingual materials including 

motivational video on CRC 

screening, pamphlet, FOBT 

instruction sheet, CRC 

informational pamphlet, CRC 

screening education from a 

health educator, and FOBT kit 

with instructions in Chinese and 

English (n = 105) 

G2: Usual care (n = 105) 

G1: 83 (68.0%) became up-todate with any CRC screening 

at follow-up (29.8 percentage 

point change from baseline; 

95% CI, 23.7- 36.0) 

G2: 24 (20.7%) became up-todate with any CRC test (4.4 

percentage point change; 95% 

CI, -0.7- 9.7) 

P < 0.001 

G1: 69.5% received FOBT
 

screening (AOR, 6.38; 95% 

CI, 3.44-11.85)
 

G2: 27.6% received FOBT
 

screening (P NR) 

128 
Table 40. Studies of interventions to eliminate structural barriers on increasing colorectal cancer screening 

rates (continued) 

Author, Year 

Study Design 

Population 

Setting 

Sample Size 

Quality Study Aims Study Groups Results 

Church et al., 2004183 

RCT, 1 year 

Residents, 50 years of age 

or older, of Wright County, 

Minnesota 

N = 1,255 

Fair 

Myers et al., 2007175 

RCT 

Primary practice patients in 

Philadelphia, Pennsylvania 

N = 1,546 

Fair 

Stokamer et al., 200485 

RCT, 6 months 

Primary care clinic at a VA 

in NYC 

N = 788 

Fair 

Test direct mailing of 

FOBT kits with and 

without reminders to 

general population 

Test targeted and 

tailored message 

delivery, both by mail 

and via phone 

outreach 

Test whether 

intensive patient 

education increases 

FOBT card return 

rates 

G1: (no reminders) Questionnaire 

mailed plus FOBT kit and 

instructional brochure (n = 434) 

G2: (reminders) Same package 

as G1, plus telephone reminders 

(n = 404) 

G3: Questionnaire only (n = 417) 

G1: “Standard Intervention” (SI) 

of mailed letter, information 

booklet, FOBT kit, and reminder 

letter (n = 387) 

G2: Standard intervention 

package plus 2 “tailored message 

pages” (TI) (n = 386) 

G3: SI plus TI, and a reminder 

phone call (TIP) by an educator 

(n = 386) 

G4: (control) Usual care (n = 387) 

G1: Educational session of 10 15 

minutes with nurse with FOBT kit 

provided with verbal instructions 

(n = 396) 

G2: Usual care, including FOBT 

kit provided with written 

instructions (n = 392) 

G1: 16.9% FOBT completion 

rate (95% CI, 11.5-22.3%) 

G2: 23.2% FOBT completion 

rate (95% CI, 17.2-29.3%) 

G3: 1.5% FOBT completion 

rate (95% CI, -2.9-5.9%) 

(P NR) 

G1: 46% screening rate 

(AOR, 1.7; 95% CI, 1.2-2.5) 

G2: 44% (AOR, 1.6; 95% CI, 

1.2-2.1) 

G3: 48% (AOR, 1.9; 9.5% CI, 

1.4-2.6) 

G4: 33% 

(P NR) 

G1: 65.9% returned FOBT 

cards 

G2: 51.3% returned FOBT 

cards (P<0.001) 

CI, confidence interval; CRC, colorectal cancer; FOBT, fecal occult blood test; G, group; N, sample size; NR, not reported; NYC, New York 

City; AOR, adjusted odds ratio; RCT, randomized controlled trial; VA, veterans administration. 

Four of these studies took place in primary care settings or clinics.85,175,179,187 All four used 

control groups that received usual care, and all assessed their outcomes through medical record 

review. The timing of followup of these four studies in this category was 6 months,85 9 

months,187 14 months,179 and 24 months.175 One good-quality study provided primarily ChineseAmericans patients from a primary care clinic with access to a health educator and culturally and 

linguistically appropriate education materials, including bilingual instructions for FOBT.179 

Another good-quality study provided patients obtaining annual flu shots in a family health clinic 

with a FOBT kit.187 One fair-quality study used a nurse to provide intensive counseling to 

patients who had agreed to FOBT.85 The final study divided patients into three groups that 

received varying levels of tailored materials to encourage screening.175 

The fifth study provided a random sample of residents in an urban area with a letter that 

included a questionnaire about CRC and screening tests.183 These investigators then gave FOBT 

kits to two intervention groups with through the mail; one group received reminders to complete 

the FOBT and the other received no reminders. The investigators assessed screening rates 

129 
through self-reported information obtained on a follow-up survey mailed to all participants 1 

year after the start of the study. 

Overview of results. In all five studies completion of screening by FOBT rose as a result of 

the interventions (14.6 to 41.9 percentage point increases in screening by FOBT). The study that 

used a culturally and linguistic appropriate intervention demonstrated the largest increase in 

screening among the studies in this section (41.9 percent). Findings from four studies 

demonstrated that interventions to eliminate barriers were effective in increasing CRC screening 

by FOBT;85,179,183,187 the fifth did not present findings specific to FOBT completion but rather 

demonstrated an increase in overall CRC screening rates.175 

Detailed results. Four of the five studies in this category were described above. One goodquality study exposed patients of Asian origin to a culturally and linguistically sensitive 

educator.179 Predominately Chinese patients who had not yet agreed to screening attended an 

intensive education session with health educators who provided culturally and linguistically 

appropriate education about CRC screening, along with a FOBT kit. The difference in return 

rates of FOBT cards between the intervention and control groups was statistically significant 

(AOR, 6.38; 95% CI, 3.44-11.85). 

The second study compared groups getting an FOBT both with and without telephone 

reminders with a control group.183 FOBT-specific findings demonstrated a statistically 

significant difference between the control group (1.5 percent; 95% CI, -2.9 - 5.9 percent) and 

both intervention groups (respectively 23.2 percent [95% CI, 17.2-29.3 percent] and 16.9 percent 

[95% CI, 11.5-22.3 percent]), for an overall difference in FOBT completion rates as high as 21.7 

percentage points. 

The third study compared groups getting three different types of interventions of varying 

intensity with a usual-care control group.175 All three intervention groups received FOBT kits. 

The control group had a 33 percent completion rate of any CRC screening test; the three 

intervention groups had the completion between 44 percent and 48 percent (G1: AOR, 1.7; [95% 

CI, 1.2-2.5]; G2: AOR, 1.6 [95% CI, 1.2-2.1]; G3: AOR, 1.9 [95% CI, 1.4-2.6]) (P-values were 

not reported). 

The nurse-based study provided patients in the intervention arm with 10- to 15-minute 

educational sessions conducted by a nurse specifically trained for this intervention.85 The 

percentage of individuals returning FOBT cards was higher in the intervention group than the 

control group (65.9 percent versus 51.3 percent; P < 0.001). 

The fifth study was conducted in a family health center in San Francisco, California.187 

Patients of the clinic (ages 50-79) were mailed multilingual flu shot campaign information and 

were given dates for obtaining flu shots. Half of the days were randomly selected in blocks of 2 

or 3 for provision of flu shots only (control group) or flu shots with FOBT kits (intervention 

group). Before each flu shot clinic, investigators gave clinic staff a list of patients with 

appointments who were eligible for a FOBT. Patients were given a handout at the clinic to 

explain the need for regular CRC testing and then a FOBT kit after their flu shot (along with 

instructions in several languages). Patients were telephoned if they had not returned a completed 

kit at 3 weeks and again (if needed) at 6 weeks. FOBT screening rates in the control group 

increased by 4.4 percentage points from 52.9 percent at baseline to 57.3 percent (P = 0.07) they 

rose in the intervention group by 29.8 percentage points from 54.5 percent to 84.3 percent 

(P < 0.001); this yielded a 25.4 percentage point difference between groups (P < 0.001). 

Provider-level interventions. Study characteristics. Two RCTs, both rated good quality, 

addressed reminder interventions targeted at provider behaviors or practices (Table 41).186,188 In 

130 
Table 41. Study of an intervention to target provider behavior for increasing colorectal cancer screening or 

followup rates 

Author, Year 

Study Design 

Population 

Setting 

Sample Size 

Quality Study Aims Study Groups Results 

Ayanian et al., 

(2008)188 

RCT, 6 months 

N = 141 physicians and 

717 patients 

Primary care practice in 

Massachusetts 

Good 

Determine 

whether 

surveillance 

colonoscopy can 

be increased 

among overdue 

patients by 

reminders to their 

primary 

physicians 

G1: Letters to physicians to G1: 9.2% completion rate for 

notify them of potential need for colonoscopy within 6 months 

colonoscopy (n = 358) G2: 4.5% completion rate (P = 0.009) 

G2: Usual care (n = 359) 

Sequist et al., 2009186 

RCT, 15 month followup 

11 Ambulatory Health 

Care Centers in 

Massachusetts 

N= 110 physicians, 

21,860 patients 

Good 

Test an 

intervention that 

provided both 

patient and 

provider 

reminders for 

screening. 

G1: Patients were mailed a 

package to remind them of need 

for CRC screening that included 

a FOBT kit, letter and pamphlet, 

and a telephone number they 

could call to make an 

appointment for endoscopy 

(n=10,930) 

G2: Usual care for patients 

(n=10,930) 

G3: Providers were given 

electronic reminders during 

office visits that patients were 

overdue for screening (n=10,912 

patients) 

G4: Usual care such that 

providers received no reminders 

(n=10,948) 

G1: 25.4% FOBT completion; 44% 

completed any CRC test 

G2: 20.4% FOBT completion 

(P < 0.001); 38.1% completed any 

CRC test (P < 0.001) 

G3: 41.9% completed any CRC test 

G4: 40.2% completed any CRC test 

(P = 0.47) 

Interaction effect between the patient 

and provider interventions was small 

and not statistically significant (-0.6%; 

95% CI, -1.2%- 0.1%; P = 0.08) 

G, group; N, sample size; P, probability/significance of findings; RCT, randomized controlled trial. 

one case providers were reminded during an office visit that a patient was overdue for CRC 

screening;186 in the other, reminder cards informed primary care physicians when a patient 

scheduled for an appointment (identified through medical record review) might need CRC 

followup.188 The outcome of obtaining CRC screening or adherence to repeat colonoscopy was 

assessed through electronic medical record review within 6 months of mailing the initial letter to 

physicians for one study or 15 months after the study was initiated.186 Both studies compared 

patients whose physicians received specific reminders with those who received usual care. 

Overview of results. One study demonstrated only minimal increase in CRC screening among 

patients with providers who received reminders compared with those who did not (41.9 percent 

versus 40.2 percent; P = 0.47).186 The other study reported a small increase in completion of 

colonoscopy within 6 months among patients whose physicians received the reminders (9.2 

percent versus 4.5 percent; P = 0.009).188 

Detailed results. One study focused on patients who may need surveillance colonoscopy and 

had received a prior colonoscopy with one or more adenomas detected but did not have a 

subsequent colonoscopy within 5 years.188 The researchers sent physicians (n = 141) in two 

networks letters via interoffice mail to notify them of the potential need of a surveillance 

131 
colonoscopy for the patients randomized to the intervention arm (n = 358). The investigators did 

not report the number of physicians who mailed letters to the patients in the intervention arm; 6 

months after the letters were initially sent to the physician, the researchers reviewed medical 

records to determine whether colonoscopies had been completed. At the same time, they also 

sent letters to physicians of patients in the control group to ensure that physicians were aware of 

the potential need for colonoscopy if clinically appropriate. Completion of colonoscopy was 

higher among patients whose physicians received reminders related to surveillance than among 

those in the control group (9.2 percent versus 4.5 percent; P = 0.009). The authors did not report 

whether the letter to the physicians, the follow-up letter to patients if it were mailed, or a 

combination of both was the factor that actually raised surveillance rates. 

The second provider-level patient reminder study involved 11 ambulatory health care centers 

in Massachusetts and targeted patients overdue for CRC screening.186 The investigators paired 

physicians with similar patterns of screening rates and referrals and then randomized one to 

receive the intervention. Throughout the 15-month study period, physicians in the centers 

received electronic reminders during office visits with patients overdue for screening. Before the 

intervention, the investigators educated physicians in both the intervention and control group on 

the use of the reminder system. Physicians could view the passive alert at any point during an 

office visit; those who received active alerts were required to acknowledge it before making any 

electronic orders. These active alerts provided current information about prior CRC screening for 

the patients and provided a “1 click” option for ordering tests. Screening rates were similar 

among patients of physicians receiving the electronic reminders compared to the control group 

(41.9 percent versus 40.2 percent; P = 0.47). 

System-level interventions. Study characteristics. Five RCTs, all rated fair quality, were 

classified as a system-level intervention because they explored the impact of various 

interventions that had been implemented within an office or health care setting with the direct 

aim of changing the system of care (Table 42). Three studies used a patient navigator to guide 

the process of obtaining a screening colonoscopy189 or a Prevention Care Manager (PCM), 

similar to a patient navigator) to assist patients in addressing barriers to obtain any CRC 

screening;162,193 two studies enhanced their systems of managing patients as they obtained other 

types of care.190-192 All studies focused on patients 50 years of age or older; one limited the age 

range of patients to those no older than 79 years.192 Three included only women.162,190-191,193 All 

included patients of health clinics or primary care practices. One study compared women in their 

intervention group to women who received an intervention to increase mammography use;162 the 

remaining four studies used patients receiving usual care as their control groups. Usual care 

included patients who were in the clinic for an office visit and did not receive exposure to the 

system level intervention. All but one study192 specifically included patients from low-income 

areas to increase CRC screening rates among populations with generally low rates. The outcome 

of interest in one study was whether a patient completed FOBT within the 6-month follow-up 

period and/or got endoscopic screening if they met national guidelines for these tests;189another 

focused on whether patients received an endoscopic screening procedure during the 1-year 

study.192 The remaining studies assessed whether patients obtained any CRC test during the 

study period with the time for followup ranging from 11 months162 to 24 months.191 All 

outcomes were assessed through medical chart review. 

132 
Table 42. Studies of interventions to target the system level for increasing colorectal cancer screening rates 

Author, Year 

Study Design 

Population 

Setting 

Sample Size 

Quality Study Aims Study Groups Results 

Dietrich et al., 2006193 

RCT, 21-month 

followup 

11 community and 

migrant health centers 

in New York City 

N= 1,413 women 

overdue for screening 

Fair 

Dietrich et al., 2007162 

RCT, 11-month 

followup 

Medicaid Managed 

Care Organization 

(MMCO) in New York 

City 

N= 626 women (50 

years or older) 

Fair 

Jandorf et al., 2005189 

RCT, 6 months 

Primary care provider 

in New York City 

N = 78 

Fair 

Ling et al., 2009192 

RCT, 1 year follow-up 

N= 10 primary care 

group practices, 599 

patients, Pittsburg, 

Pennsylvania 

N = 599 

Fair 

Evaluate the 

effect of a 

telephone support 

intervention to 

increase rates of 

breast, cervical, 

and CRC cancer 

screening among 

minority and lowincome women. 

Test a “prevention 

care 

management” 

approach to 

improve breast, 

cervical, and 

colorectal 

screening rates 

among enrolled 

women in a 

MMCO. 

Test the 

effectiveness of a 

patient navigator 

in increasing 

screening 

colonoscopy. 

Evaluate methods 

to promote 

endoscopic 

screening in 

primary care 

practice. 

G1: PCM worked with patients to 

address barriers, including providing 

motivational intervention. Physician 

recommendations were provided to 

all patients via letter or in the office. 

Mailing of FOBT was done but data 

NR. (n = 706) 

G2: Usual care which included one 

single call to answer questions and 

advise of need for screening. (n = 

707) 

All received an intervention to 

receive reminder calls for a 

mammogram. In addition: 

G1: Prevention Care Manager (PCM) 

worked with patients to overcome 

barriers and schedule appointments 

(n = 317) 

G2: Affinity Mammogram Outreach 

Program (AMOP) followed up with all 

patients to provide additional 

educational materials on all cancer 

screenings and a follow-up telephone 

call to remind them of need for 

screening (n = 309) 

G1: Patient navigator plus placement 

of FOBT card in chart (n = 38) 

G2: FOBT card placed in chart; 

physicians were asked to 

recommend screening to patients 

(n = 40) 

G1: Enhanced management 

practices (including training of 

physicians and office staff; 

implement office protocols; 

motivational interviews to counsel 

patients; assist patient in overcoming 

barriers) with a tailored letter to 

patients (n = 152) 

G2: Enhanced management 

practices with no tailored letter to 

patient (n = 190) 

G3: Nonenhanced management 

practices (includes training of 

physicians and office staff, 

G1: 63% obtained any CRC test 

in follow-up period (0.24 point 

change from baseline) 

G2: 50% obtained any CRC test 

(0.11 point change from baseline) 

0.13 point difference between G1 

and G2 (95% CI, 0.07-0.19) 

(P<0.001) 

G1: 32% up-to-date for any CRC 

test at follow-up 

G2: 25% up-to-date for any CRC 

test at follow-up (AOR, 1.69; 95% 

CI, 1.03-2.77) 

P = 0.04 

G1: 23.7% completion rate for 

endoscopy; 42.1% for FOBT 

G2: 5% completion rate for 

endoscopy (P = 0.019); 25.0% 

for FOBT (P = 0.086) 

G1: 81 (53.3%; 95% CI, 45.4­

61.2) completed endoscopic CRC 

screening 

G2: 103 (54.2%; 95% CI, 47.1­

61.3) completed endoscopic test 

G3: 58 (43.6%; 95% CI, 35.2­

52.0) completed endoscopic test 

G4: 47 (37.9%; 95% CI, 29.4­

46.4) completed endoscopic test 

Enhanced management 

practices yielded 1.63-fold 

increase (95% CI, 1.11- 2.41; 

P = 0.01) 

133 
Table 42. Studies of interventions to target the system level for increasing colorectal cancer screening rates 

(continued) 

Author, Year 

Study Design 

Population 

Setting 

Sample Size 

Quality 

Ling et al., 2009192 

Study Aims Study Groups 

writing of office protocols) with 

Results 

(continued) tailored letter to patients (n=133) 

G4: Nonenhanced management 

practices with no tailored letter 

(control group) (n=124) 

Roetzheim et al., 

2004;190 Roetzheim, et 

al., 2005191 

RCT (cluster 

randomized at clinic 

level), 12-month 

followup190 and 24- 

month followup)191 

8 county-funded clinics 

in Florida 

N= 1,196 at baseline; 

1,237 at 12-month 

followup; 1,296 at 24­

month followup 

Fair 

Assess the 

efficacy of the 

Cancer Screening 

Office Systems 

(Cancer SOS) to 

increase cancer 

screening in 

primary care 

settings serving 

disadvantaged 

populations. 

G1: Patients were asked to 

complete a cancer screening 

checklist to indicate which tests 

they were due to receive; 

stickers were then placed on 

charts to flag providers of need 

for screening; staff trained and 

unannounced audits done; 

formal feedback of screening 

rates given to practices at 6 and 

12 months (each time point at 

different independent random 

samples drawn from medical 

records) (n=600) 

G2: Usual care (n=596) 

G1: 40.1% FOBT completion rate 

G2: 11.9% FOBT completion rate 

AOR 2.56 for FOBT completion rate; 

95% CI, 1.65-4.01 (P< 0.0001) at 12 

months 

No effect on FOBT completion at 24 

months (AOR 1.17; 95% CI, 0.92­

1.48; P= 0.19) 

CI, confidence interval; CRC, colorectal cancer; FOBT, fecal occult blood test; G, group; MMOC, Medicaid Managed Care Organization; N, 

sample size; NR, not reported; P, probability; PCP, primary care provider; RCT, randomized controlled trial. 

Overview of results. All five studies found statistically significant increases in CRC 

screening rates for their tests of interest; absolute increases in screening ranged from about 5 

percentage points to 28.2 percentage points. The screening colonoscopy study found a 

statistically significant increase in completed endoscopy at 6 months (23.7 percent versus 5.0 

percent; P = 0.019).189 The two studies that included a PCM providing assistance in addressing 

barriers to screening demonstrated similar findings: women in a Medicaid managed care 

organization had a 14 percent increase in screening rates when the PCM worked with them 

compared with a 9 percent increase in the control group (P = 0.04);162 among women in 

community and migrant health care clinics in New York City receiving the intervention had a 13 

percentage point difference in screening rates compared with the control group (AOR, 0.13; 95% 

CI, 0.07-0.19).193 In the study of primary care practice patients who received enhanced office and 

patient management practices at randomly selected practices, the investigators reported a 1.63­

fold increase in CRC screening among patients in the intervention clinics compared with those in 

control clinics (95% CI, 1.11-2.41; P = 0.01).192 In the study that randomized patients at the 

clinic level to complete cancer screening checklists placed in their medical charts at the time of 

an office visit, along with a sticker flagging the provider for the need for screening, demonstrated 

that patients in the intervention group were 2.56 times more likely to obtain an FOBT at the 12­

month followup than the control group (AOR, 2.56; 95% CI, 1.65-4.01; P < 0.0001),190 but this 

effect was diminished at 24 months (AOR, 1.17; 95% CI, 0.92-1.48; P = 0.19).191 

134 
Detailed results. The studies using PCM staff to help patients obtain CRC screening were 

each conducted in New York City clinics: one in a Medicaid managed care organization 

(MMCO)162 and the other in 11 community and migrant health care clinics.193 Neither study 

provided racial or ethnic statistics of the women in their samples. The MMCO study involved 

women who were receiving an intervention of patient reminders to obtain mammography 

screening; it randomly assigned women to receive PCM assistance in obtaining CRC screening. 

The PCM assistance included a detailed script read to patients to explain the importance of CRC 

screening and types of available tests and assistance overcoming any barriers to screening, 

including making appointments for patients to receive tests.162 Those in the comparison group 

received educational materials about CRC screening and one telephone call to recommend that 

they obtain CRC screening. At the 11-month followup, those in the group receiving PCM 

assistance were more likely than the women in the comparison group to be up to date with any 

CRC screening (P = 0.04). The other study (by many of the same authors) applied a similar 

intervention to a different setting.193 In this study, PCMs received 7 hours of training for their 

role, worked with patients to overcome barriers, and provided motivational counseling during the 

study. For two of 11 centers, the PCM could also mail FOBT kits to patients; differences related 

to this aspect of the intervention were not reported. Those in the comparison group received 

usual care, which in the participating clinics included a single call to patients to answer any 

questions about CRC screening and advise them about the need to be screened. Those receiving 

PCM assistance were more likely than the control group to obtain CRC testing (0.13 difference 

in screening rates; 95% CI, 0.07-0.19). 

For the study in which a patient navigator helped patients obtain screening colonoscopy, 

patients eligible for the study had been referred for CRC screening after an appointment with a 

primary care provider.189 Patients were “navigated” in an effort to improve compliance with 

referrals to screening colonoscopy. Patients, from a federally qualified health center in New 

York City serving predominantly minority and low-income patients, were 50 years of age or 

older and eligible for CRC screening. More than 70 percent were female, about 80 percent were 

Hispanic, and less than half of the participants spoke English. Those patients randomly assigned 

to the intervention received patient navigation; those assigned to the control group received usual 

care, which included placement of an FOBT card in the patient’s chart to remind his/her 

physician of the need for screening. The patient navigator contacted patients in the intervention 

group 2 to 3 weeks after the patient agreed to participate and provided education about CRC 

screening by telephone. The patient navigator continued to provide written reminders, further 

telephone calls, and scheduling assistance to the intervention group. Using completion of an 

endoscopic examination as a key outcome, the authors reported that patient navigation improved 

completion of these tests within 6 months of physician recommendation (15.8 percent 

compliance in the navigated group versus 5 percent in the nonnavigated group; P = 0.019).189 

Another study focused on several aspects of providing enhanced office and patient 

management among 10 primary care practices in Pennsylvania to increase endoscopy 

screening.192 All patients determined to be eligible for the study were mailed letters from their 

physicians recommending endoscopic CRC screening and asked patients to phone for an 

appointment. These letters were either tailored or nontailored; findings specific to this aspect of 

the intervention were discussed earlier in the “small media” category. Patients in the control 

group had office visits in practices that had received educational workshops for their physicians 

and office staff on improving CRC screening and written protocols on systematically 

implementing screening. Clinics randomly assigned to the intervention received this information 

and assistance in implementing the office protocols and tracking patient acceptance of referral 

for endoscopic screening. The research team then conducted motivational interviewing with 

135 
patients who had not obtained screening within 3 months after receiving a physician 

recommendation (by mail) to do so. During these interviews, staff worked with the patients to 

address any barriers to obtaining screening (e.g., scheduling appointments, obtaining 

transportation, addressing insurance needs). Medical records were reviewed within a year after 

the initial letter was mailed to assess screening rates. The study demonstrated a 1.63-fold 

increased odds of completing a colonoscopy or FS among patients in the intervention (95% CI, 

1.11-2.41; P = 0.01).192 

The results of the final study in this category were published in two articles; one presented 

12-month findings190 and the 24-month results.191 In this study, the investigators randomized 

eight county-funded clinics in Florida as control or intervention sites. Patients receiving care at 

the control sites received usual care specific to CRC screening. Those receiving care at the 

intervention sites were asked to complete a cancer screening checklist at the time of an office 

visit. The checklist indicated the tests they had previously received and when each was obtained. 

Based on these responses, medical charts were flagged with stickers to indicate to the provider 

whether a patient was due for CRC screening. Before implementing this process, the research 

team also trained staff about the need for CRC screening. Throughout the 12-month study, the 

team also made unannounced visits to the clinics to conduct chart audits and then gave formal 

feedback to staff of their screening rates. They also abstracted data from medical records of 

independent random samples of patients at baseline and at each of the two follow-up periods to 

determine the extent to which patients had obtained CRC screening. At 12 months, the study 

demonstrated a 28.2 percentage point increase among patients receiving care at the intervention 

sites compared to the control sites (40.1 percent versus 11.9 percent; P< 0.0001).190 At 24 

months, the difference in screening rates across sites was smaller (28.2 percent versus 12.6 

percent; P = 0.19).190 

KQ 4: Current and Projected Capacity to Deliver Colorectal 

Cancer Screening and Followup 

If efforts to increase screening rates for CRC are successfully implemented, providers and 

health care systems must be able to handle the resultant increased demand for services, 

particularly for endoscopic procedures, that will be needed both for primary screening and for 

follow-up of abnormal screening results from noninvasive screening strategies. Note that to 

avoid confusion over the use of the word ‘surveillance’, we refer to monitoring of patients after 

receipt of abnormal results as ‘followup’. As shown in the analytic framework (Figure 1, Chapter 

2), capacity to deliver CRC screening is an important variable in determining the populationlevel benefit from screening. This key question (KQ) addresses the current and projected 

capacity of the health care system to deliver CRC screening and followup for the US population. 

In this section we have defined key terms as follows: 

•	 Current capacity (or current potential volume): the sum of current volume and additional 

available capacity, where: 

o	 Current volume is the estimate of the current number of FS or colonoscopy 

procedures conducted in the present year; and 

o	 Additional available capacity is the number of additional FS or colonoscopy 

procedures that could be conducted in the current year; 

•	 Projected capacity: future capacity to conduct FS or colonoscopy under various scenarios 

such as changes in workforce or changes in the number of facilities that provide 

procedures; 

136 
•	 Ability to meet projected demand: the ability of current capacity (or projected capacity if 

known) to meet the projected demand under various demand scenarios, such as screening 

the entire eligible US population with a specific test. 

Although this KQ gave priority to projected capacity of FS or colonoscopy, we found no 

studies that examined this topic. Most common were studies that provided estimates of current 

volume of FS or colonoscopy and compared those estimates with a projected demand. In this 

section, not only do we compile the varying estimates of current capacity and projected demand 

across studies and evaluate the strength of evidence of these estimates, but we also compare the 

estimate of current capacity based on multiple studies with that of projected demand, based on 

multiple studies. This approach enables us to answer better than heretofore the question of the 

nation’s ability to meet projected demand. 

In addition to the concepts defined above, we found data on current volume by provider type 

and geographic variation in current volume and additional available capacity.61,195-197 Because 

these measures are related to our outcomes of current volume and additional available capacity, 

we have completed summary tables and text for these and included them as Appendix G.‡‡ We 

also found four studies that report on current volume and additional available capacity in 

individual states.61,195-196,198 Because results from these studies did not change our conclusions 

from the national data, we have included them as part of Appendix G rather than in the main text. 

We present our overall summary and strength of evidence tables for studies addressing this 

KQ at the beginning of this section. The remainder of this section provides a more detailed 

assessment of the individual studies that informed our conclusions and our assessment of the 

strength of evidence. 

KQ 4 Overall Summary and Strength of Evidence 

In Table 43, our overall grades of the strength of evidence appear in the far right column; 

grades for key domains to determine the strength of evidence (risk of bias, consistency, 

directness, and precision) are in the intermediate columns. In assessing research specific to KQ 4 

about capacity for increasing CRC screening, we ultimately had grades of only low strength of 

evidence. Low means that we have only low confidence that the evidence reflects the true effect; 

further research is likely to change the confidence in the estimate of effect and is likely to change 

the estimate.31 

Overall, evidence suggests that FS current volume is not sufficient to meet projected demand 

if a significant proportion of the population is screened by either FS or FOBT/FS. Current 

volume of colonoscopy is likely to be sufficient to meet projected demand if a significant 

proportion of the US population is screened by FOBT or FS but not by colonoscopy. Based on 

one study’s estimates of additional available capacity, current capacity for FS is sufficient for a 

screening program by FOBT/FS or FS alone, and current capacity for colonoscopy may be 

sufficient for a screening program by colonoscopy alone. All these estimates represent steadystate scenarios. 

‡‡ Appendixes and Evidence Tables for this report are provided electronically at 

http://www.ahrq.gov/downloads/pub/evidence/pdf/crcuse/crcuse.pdf. 

. 

137 
Table 43. Strength of evidence for the current and projected capacity to deliver CRC screening 

Overall 

Number of studies Risk of Bias Consistency Directness Precision Results 

strength of 

evidence 

Current capacity: FS 

Brown et al., 2003195 

Seeff et al., 2004196 Moderate Inconsistency 

present 

Direct NR Current volume: 

2.8-4.9 million 

Low 

2 cross- FS 

sectional/1 

Good, 1 Fair Additional 

available 

capacity: 6.7 

million FS 

Current capacity: COLON 

Brown et al., 2003195 

Hur et al., 2004199 

Seeff et al., 2004196 

Vijan et al., 2004200 

Moderate 

4 Cross 

sectional/1 

Good, 3 Fair 

Inconsistency 

present 

Direct NR Current 

volume:1.6-6.6 

million 

colonoscopies 

Low 

Additional 

available 

capacity: 8.2 

million 

colonoscopies 

Ability to meet projected demand: FOBT Demand scenario 

Ladabaum and 

Song, 2005201 

Brown et al., 2003195 

Hur et al., 2004199 

Seeff et al., 2004196 

Vijan et al., 2004200 

Moderate 

Capacity: 

4 Cross 

sectional/1 

Good, 3 Fair 

Capacity: 

Inconsistent 

Demand: 

Consistency 

unknown (single 

Indirect NR 

study) 

Demand: 1 

Modeling/1 

Good 

Current Low 

capacity: 

9.8-14.8 million 

colonoscopies 

Demand: 

3.8 million 

colonoscopies 

Ability to meet projected demand: FS Demand scenario 

Ladabaum and 

Song, 2005201 

Brown et al., 2003195 

Seeff et al., 2004196 

Moderate 

Capacity: 

2 Cross 

Capacity: 

Inconsistency 

present 

Indirect NR Current 

capacity: 9.5­

11.6 million FS 

Low 

sectional/1 Demand: Demand: 

Good, 1 Fair No 10 million FS 

Inconsistency 

Demand: 

2 Modeling/1 

Good, 1 Fair 

Ladabaum and 

Song, 2005201 

Brown et al., 2003195 

Hur et al., 2004199 

Seeff et al., 2004196 

Vijan et al., 2004200 

Moderate 

Capacity: 

4 Cross 

sectional/1 

Good, 3 Fair 

Capacity: 

Inconsistency 

present 

Demand: 

Consistency 

Indirect NR Current 

capacity: 9.8­

14.8 million 

colonoscopies 

Demand: 2.7 

Low 

unknown (single million 

Demand: 1 study) colonoscopies 

Modeling/1 

Good 

138 
Table 43. Strength of evidence for the current and projected capacity to deliver CRC screening (continued) 

Overall 

Number of studies Risk of Bias Consistency Directness Precision Results 

strength of 

evidence 

Ability to meet projected demand: FOBT/FS Demand scenario 

Ladabaum and 

Song, 2005201 

Brown et al., 2003195 

Seeff et al., 2004196 

Moderate 

Capacity: 

2 Cross 

Capacity: 

Inconsistency 

present 

Indirect NR Current 

capacity: 9.5­

11.6 million FS 

Low 

sectional/1 Demand: 

Good, 1 Fair Consistency Demand: 6.9 

unknown (single million FS 

Demand: study) 

1 Modeling/1 

Good 

Ladabaum and 

Song, 2005201 

Hur et al., 2004199 

Seeff et al., 2004196 

Vijan et al., 2004200 

Moderate 

Capacity: 

4 Cross 

sectional/1 

Capacity: 

Inconsistency 

present 

Demand: 

Indirect NR Current 

capacity: 9.8­

14.8 million 

colonoscopies 

Low 

Good, 3 Fair Inconsistency Demand: 2.9­

present 4.7 million 

Demand: colonoscopies 

2 Modeling/1 

Good, 1 Fair 

Ability to meet projected demand: Colonoscopy Demand scenario 

Brown et al., 2003195 

Seeff et al., 2004196 

Vijan et al., 2004200 

Moderate 

Capacity: 

Capacity: 

Inconsistency 

present 

Indirect NR Current 

capacity: 9.8­

14.8 million 

Low 

4 Cross colonoscopies 

sectional/1 Demand: 

Good, 3 Fair Inconsistency Demand: 4.8­

present 8.1 million 

Demand: colonoscopies 

3 Modeling/2 

Good, 1 Fair 

Ability to meet projected demand: Screening the unscreened using additional available capacity 

Seeff, et al., 2004202 Moderate Consistency Direct NR Using 100 Low 

unknown (single percent of 

1 Cross study) additional 

sectional/1 Good available 

capacity, it 

would take 5 

years to screen 

the unscreened 

population with 

colonoscopy 

Current capacity, current volume + additional available capacity. COLON, colonoscopy; FOBT, fecal occult blood test; FS, flexible 

sigmoidoscopy. NR, not reported 

If the US were to adopt a colonoscopy-only approach to CRC screening, either colonoscopy 

capacity would need to be substantially increased or at least 5 years would be required to do the 

“catch-up” screening required to screen people who have not been screened. 

Overall capacity study characteristics. We found six studies (seven articles) of good or fair 

quality that reported national estimates of current capacity (current volume and/or available 

capacity), projected demand, and ability of current capacity to meet projected demand.195-196,199­

139 
203 We rated one additional study as poor quality and did not include it because it did not 

incorporate increased demand for surveillance colonoscopy following use of FOBT in its 

demand estimates.204 

All six included studies reported on current volume or additional available capacity for one 

or more of the following screening procedures: FS, colonoscopy, or CT colonography. No study 

reported on these outcomes for FOBT, although FOBT screening is included in the various 

demand scenarios that are examined. Five of the studies (five articles) included estimates of both 

current and projected demand.195,199-200,202-203 One article reported only estimates of current 

capacity (current volume as well as additional available capacity).196 One study modeled only 

projected demand under different demand scenarios.201 Among the five studies that reported on 

both capacity and demand, a single study can have different quality ratings for these two separate 

parts of the study. 

Of the five studies (six articles) that report on current capacity, two studies obtained the data 

through national surveys, either of endoscopic facilities196,202 or of endoscopic providers195; both 

sets of respondents reported on the number of FSs or colonoscopies they perform per week or 

month. These studies both reported on volume of both FS and colonoscopy, and one of the two 

reported on additional available capacity of FS and colonoscopy as well. Two studies,199-200 

which reported only on current volume of colonoscopy, conducted secondary analyses of a 

database from the Clinical Outcomes Research Initiative (CORI), a voluntary consortium of 400 

endoscopists at 42 sites in 22 states. The final study, which reported on current volume of CT 

colonography, used secondary data on CT scanners in the United States for its estimates.203 

Six studies that reported projected demand used a variety of mathematical models to do so. 

For their modeling, investigators used various refinements of population estimates, e.g., 

population growth, percentage of population that are at high risk because of family history or 

inflammatory bowel disease, and the percentage of the population ineligible for screening 

because of comorbid conditions. Also, a critical assumption in the modeling of demand that 

varied across these studies was the percentage of persons participating in screening overall; this 

figure ranged from 40 percent to 100 percent. A subset of key assumptions for each study is 

noted in the tables. 

Overall capacity study results. Table 44 provides an overview of the results for KQ 4. In 

each row are the types of procedures for which the outcomes of capacity and demand were 

available (total FS, total colonoscopy, and screening colonoscopy); the columns contain the 

outcomes of current capacity (current volume and additional available capacity) and projected 

demand under various demand scenarios. For each demand scenario, we also present an 

assessment of whether current capacity is able to meet projected demand. 

Studies varied in their estimates of current volume of FS procedures (2.8 million to 4.9 

million) and screening colonoscopy procedures (1.6 million to 6.6 million) (Table 44). A single 

study provided estimates of additional available capacity of 6.7 million FSs and 8.2 million 

colonoscopies. 

Results of the modeling studies suggest that current volume of FS is not sufficient to meet 

projected demand if a significant proportion of the population is screened by FS or FOBT/FS. 

Current volume of colonoscopy is likely to be sufficient to meet projected demand if a 

significant proportion (70 percent to 75 percent) of the US population is screened by FOBT or 

FS but not by colonoscopy. Only one estimate of additional available capacity is available; based 

on this study’s results, current capacity for FS is sufficient for a screening program by FOBT/FS 

or FS alone. Based on this study’s estimates of additional available capacity for colonoscopy, 

140 
Table 44. Overview of results of capacity studies 

Projected Demand: 

Projected Demand: Projected Demand: Projected Demand: Colonoscopy 

Current Capacity FOBT Scenario FS Scenario FS/FOBT Scenario Scenario 

Additional Able To Able To Able To Able To 

Type of 

Procedure 

Current 

Volume 

Available 

Capacity Number 

Meet 

Demand? Number 

Meet 

Demand? Number 

Meet 

Demand? Number 

Meet 

Demand? 

FS (total) 2.8-4.9 6.7 million 10 million Yes* 6.9 Yes* 

million million 

Colonos­ 4.0­ 3.8 Yes 2.7 Yes 2.9-4.7 Yes 

copy (total) 14.2 million million million 

million 

Colonos­ 1.6-6.6 8.2 million 4.8-8.1 Yes* 

copy 

(screening) 

million million 

FOBT, fecal occult blood test; FS, flexible sigmoidoscopy. 

* If additional available capacity is included in calculations. 

current capacity for colonoscopy may be sufficient for a screening program by colonoscopy 

alone. 

All these estimates represent steady-state scenarios. None of these models incorporated 

current estimates of the unscreened. In the single study that modeled available capacity to screen 

the unscreened population, using 100 percent of additional available capacity, it would take 3 

years at current screening patterns, 6 years using 100 percent FS or FOBT/FS, or 5 years using 

100 percent colonoscopy to screen the unscreened population. 

National-Level Estimates of Current Capacity of Endoscopy Screening 

This section consists of two parts. We first describe the studies that present data on current 

volume of endoscopy screening. We next describe studies of additional available capacity of 

endoscopy. 

Current volume of endoscopy. Study characteristics. Four studies provided national-level 

estimates of current volume of endoscopy; all four provided estimates for colonoscopy195-196,199­

200 and two also did so for FS (Table 45).195-196 Two studies reporting estimates for both FS and 

colonoscopy195-196 obtained the data through national surveys, either of endoscopic facilities196 or 

of endoscopic providers.195 In these studies the facility or provider reported the number of 

colonoscopies they perform per week or month. The remaining two studies,199-200 which reported 

only on current volume of colonoscopy, report analyses of a database from the Clinical 

Outcomes Research Initiative (CORI), a voluntary consortium of 400 endoscopists at 42 sites in 

22 states. The year for which current volume was reported in these studies varied from 2000 

through 2003. Current volume in each of these studies was compared with projected demand 

(described in the section below, “National Estimates of Ability to Meet Projected Demand for 

Endoscopy, by Different Demand Scenarios”). 

We rated one study as good quality196 and three studies as fair.195,199-200 Two of the three 

rated fair quality199-200 received this rating because they extrapolated data from a limited dataset 

of voluntary gastroenterologist physicians to estimate the number of colonoscopies performed by 

the entire number of gastroenterologists in the United States. The third study195 was rated fair 

quality because of limitations in measurement of the outcome. 

141 
Table 45. National estimates of current volume of endoscopy screening 

Quality 

Rating for 

National 

Author, Year Estimates of 

Study Design Data Collection or Current 

Setting Estimation Results Volume 

Seeff et al., 2004 (CDC)196 Current volume and Current volume (2002): Good 

additional estimated by 2.8 million FSs 

Cross-sectional survey of national sample 14.2 million colonoscopies 

of practices performing FS 

National sample of or colonoscopy 1.5 million FSs for screening (54%) 

endoscopy practices 6.6 million colonoscopies for screening (47%) 

Brown et al., 2003 (NCI)195 Current volume estimated Current volume (2000): Fair 

by survey of national 4.9 million FSs 

Cross-sectional and sample of primary care 4.0 million colonoscopies 

modeling physicians, 

gastroenterologists, and 1.6 million colonoscopies for screening (40%) 

National sample of general surgeons 

physicians Average colonoscopies per month performed 

by: 

US population general surgeons, 8; 

gastroenterologists, 32 

Hur et al., 2004199 Current volume of Current volume (2003): Fair 

colonoscopy estimated 6.47 million colonoscopies 

Secondary data analysis from CORI database; 

and modeling 2001 data used and 1.98 million colonoscopies for screening (29%) 

inflated to reflect national 

US population trends 

Vijan et al., 2004200 Current volume of Current volume (2002-2003): Fair 

colonoscopy conducted by Average 21 colonoscopies per endoscopist per 

Secondary data analysis gastroenterologists month 

and modeling estimated from CORI 

database; estimates were Estimated 1.27 million colonoscopies per year 

US population	 increased by 33% to conducted by gastroenterologists for screening 

include nongastro- Estimated 1.69 million colonoscopies per year 

enterologist providers conducted by all types of providers 

46% of colonoscopies for screening 

Average number of colonoscopies per month: 

21 (range 0-102) 

CORI, Clinical Outcomes Research Initiative; FS, flexible sigmoidoscopy. 

Overview of results. Studies varied in their estimates of current volume of FS and 

colonoscopy. Differences between this study and the three fair-quality studies (giving data for, 

variously, 2000 to 2003) were greater for estimates of current volume of screening colonoscopy 

(1.6 to 6.6 million colonoscopies per year among four studies) than for FS (2.8 to 4.9 million per 

year in two studies). Differences may reflect differing methods of data collection or underlying 

issues of validity of self-report or report of volume by clinic administrators; they may also be 

consistent with increases in current volume of colonoscopy over a short period and concurrent 

decreases in current FS volume. 

Detailed assessment, colonoscopy. In the good-quality study, authors from the Centers for 

Disease Control and Prevention (CDC) surveyed a national sample of 1,809 endoscopic facilities 

in the United States.196 They identified practices using lists of facilities known to have purchased 

or leased lower endoscopic equipment between 1996 and 2000 and then screened practices by 

telephone to ensure that they did in fact conduct CRC screening. A physician or clinic 

142 
administrator completed this survey. The survey, which achieved a response rate of 74 percent, 

found that, in 2002, 6.6 million screening colonoscopies had been conducted. 

Three studies rated fair quality produced similar estimates of the current volume of 

colonoscopy, but their results differed from those from the CDC study.195,199-200 One study, 

conducted by the National Cancer Institute (NCI),195 surveyed a national sample of primary care 

physicians, gastroenterologists, and general surgeons to estimate the current volume of 

colonoscopy among these providers nationally. The study did not adjust estimates of current 

volume for procedures by other types of providers. The NCI study estimated current colonoscopy 

volume in 2000 to be 4.0 million, including 1.6 million colonoscopies for screening. The two 

studies using data from the CORI database199-200 reported results similar to those of the NCI 

study. The first found that, in 2003, the estimated current volume (provided by 

gastroenterologists alone) was 6.47 million colonoscopies, with 1.98 million for screening; 199 

the second estimated that, in 2002-2003, the current volume for screening colonoscopy, adjusted 

to estimate colonoscopies done by all provider types, was 1.69 million.200 

Several differences in methods may account for the widely varying estimates among the four 

studies. Results from the two CORI-based investigations are likely based on nonrepresentative 

data, as the dataset includes volunteer physicians participating in this registry. Of the two studies 

with the stronger methods, the CDC study was conducted 3 years later than the NCI study and 

asked for actual numbers of procedures; the NCI study gave categories for response with ranges 

such as “11-20 procedures.” The highest category was “more than 20 procedures” per month, 

which may have set a potentially inaccurate ceiling on numbers for very active endoscopists. The 

CDC study also surveyed endoscopy practices, whereas the NCI study surveyed three types of 

providers; thus, the latter study may have missed perhaps up to 8 percent of colonoscopies (based 

on data from the CDC study). 

Studies varied as to whether the investigators included surveillance colonoscopies in 

estimates of current volume. In the two CORI studies, one included such procedures200 and the 

other did not.199 In the NCI study, the authors could not determine whether respondents classified 

followup procedures as screening or diagnostic.195 (We contacted the author of the CDC study 

but received no response.) All four studies provided estimates of the percentage of all 

colonoscopies that are conducted for screening purposes: 29 percent,199 40 percent,195 and 46 

percent.196,200 Two studies estimated the average number of procedures per month: 32 for 

gastroenterologists and 8 for colorectal surgeons195 and, in another study, 21 for 

gastroenterologists.200 

Detailed assessment, FS. Two estimates of current volume for FS were available. The NCI 

study estimated the 2000 current volume of FS at 4.9 million;195 the CDC study estimated that 

the 2002 FS current volume was 2.8 million.196 

Additional available capacity of endoscopy. Study characteristics. The CDC study reported 

on additional available capacity of FS and colonoscopy at the national level (Table 46).196 This 

study was a survey of a national sample of 1,809 endoscopic practices; they reported the number 

of colonoscopies they perform per week and the weekly maximum number they could perform. 

143 
Table 46. National estimates of additional available capacity of endoscopy screening 

Author, Year 

Study Design 

Setting 

Seeff et al., 2004196 

Data Collection 

Additional available 

Results 

Current volume (2002): 

Quality Rating 

Good 

capacity estimated by 2.8 million FSs 

Cross-sectional survey of sample of 14.2 million colonoscopies 

practices performing FS 

National sample of or colonoscopy 1.5 million FS for screening (54%) 

endoscopy practices 6.6 million colonoscopies for screening (46%) 

Additional available capacity: 

6.7 million FSs (239%) 

8.2 million colonoscopies (58%) 

FS, flexible sigmoidoscopy. 

Overview of results. The CDC article reported additional available capacity in 2002 of 6.7 

million for FS (239 percent of current volume) and 8.2 million for colonoscopy (58 percent of 

current volume).196 

Detailed assessment. The CDC study asked respondents (clinic physicians or administrators) 

to estimate the weekly number of FSs and colonoscopies that the practice performed per week, 

and the weekly potential maximum the practice could perform. Available capacity was 

determined by subtracting the current volume from the maximum. For national estimates, these 

investigators imputed missing values of these numbers and incorporated weights into their 

analysis to make estimates generalizable to all US health care practices that use endoscopic 

equipment for CRC screening. 

National Estimates of Ability to Meet Projected Demand for 

Endoscopy, by Different Demand Scenarios 

Projected demand. Study characteristics. Six studies provided estimates at the national level 

of ability of current volume or additional available capacity to meet projected demand for 

endoscopy (Table 47). Many of these studies evaluated ability to meet demand for colonoscopy, 

even under screening scenarios using FOBT or FS, as it is capacity for colonoscopy that is most 

likely restricted and is of most interest. 

We rated three studies as good quality195,201-202 and two studies as fair quality;199,203 for a 

sixth study, we rated separate parts as good and fair.200 The studies rated fair quality received this 

rating because of either the representativeness of the data used to estimate capacity or the 

assumptions made for modeling demand. We rated an additional study as poor quality and 

excluded it because it did not incorporate increased demand for surveillance colonoscopy 

following use of FOBT in its estimates.204 

Two studies collected and analyzed survey data of physicians or endoscopic facilities to 

estimate current volume and additional available capacity.195,202 Of the four other studies that 

estimated capacity, two studies used secondary data from a survey of endoscopic 

practitioners,199-200 one study used secondary data providing the number of CT scanners,203 and 

the final study modeled only demand and did not have estimates of current or additional 

available capacity.201 

144 
Table 47. National estimates of ability of current volume or additional available capacity of flexible 

sigmoidoscopy or colonoscopy to meet projected demand for endoscopy, by different demand scenarios 

Author, Year Data Collection or 

Study Design Data Inputs for Model Description to Quality 

Setting Capacity/Volume Project Demand Results Rating 

Demand scenario: all FOBT screening 

Ladabaum et al., 2005201 None	 Current and projected Assuming 75% uptake, Good 

demand (in various demand for colonoscopy 

screening scenarios) would be 3.8 million if all 

estimated by Markov screening by FOBT 

model 

Brown et al., 2003195 

Cross-sectional and 

modeling 

National sample of MDs; 

US population 

Demand scenario: FS screening every 5 years 

Ladabaum et al., 2005201 None	 Current and projected Assuming 75% uptake, Good 

demand (in various demand for FS would be 10 

screening scenarios) million and demand for 

estimated by Markov colonoscopy would be 2.7 

model million if all screening by FS 

Current volume 

estimated by survey of 

national sample of 

primary care physicians, 

gastroenterologists, and 

general surgeons 

Demand estimated by 

microsimulation model 

that incorporates 

population estimates, 

assumptions about test 

performance and 

screening program 

policy 

Assuming 70% adherence: 

screening of national 

population with FS every 5 

years would require the 

delivery of “almost 10 million” 

FSs in 2000 (2 times current 

volume) 

Fair 

Demand scenario: annual FOBT/FS every 5 years 

Ladabaum et al., 2005 None	 Current and projected Assuming 75% adherence, Good 

(2887)201	 demand (in various demand for FS would be 6.9 

screening scenarios) million and demand for 

estimated by Markov colonoscopy would be 4.7 

model million if all screening by 

FOBT/FS 

Vijan et al., 2004200 Current volume of 

colonoscopies 

Secondary data analysis conducted by 

and modeling gastroenterologists 

estimated by analysis of 

US population CORI database 

Demand estimated by 

Markov model; number 

of lifetime 

colonoscopies and FSs 

per patient for the US 

population under 

various scenarios 

Assuming 70% adherence, 

an FOBT/FS screening 

strategy would require an 

incremental number of 1.2 

million colonoscopies (above 

baseline of 1.69 million per 

year) 

Assuming 100% adherence, 

an FOBT/FS screening 

strategy would require an 

incremental number of 2.39 

million colonoscopies (above 

baseline of 1.69 million per 

year) 

Demand scenario: all colonoscopy screening 

Ladabaum et al., 2005201 None Current and projected Assuming 75% uptake, Good 

demand (in various demand for colonoscopy 

screening scenarios) would be 8.1 million if all 

estimated by Markov screening by colonoscopy 

model 

Fair (volume 

estimates) 

Good 

(demand 

estimates) 

145 
Table 47. National estimates of ability of current volume or additional available capacity of flexible 

sigmoidoscopy or colonoscopy to meet projected demand for endoscopy, by different demand scenarios 

(continued) 

Author, Year Data Collection or 

Study Design Data Inputs for Model Description to Quality 

Setting Capacity/Volume Project Demand Results Rating 

Vijan et al., 2004200 

Secondary data analysis 

and modeling 

US population 

Brown et al., 2003195 

Cross-sectional and 

modeling 

National sample of MDs; 

US population 

Current volume 

estimated by survey of 

national sample of 

primary care physicians, 

gastroenterologists, and 

general surgeons 

Demand estimated by 

microsimulation model 

that incorporates 

population estimates, 

assumptions about test 

performance, and 

screening program 

policy 

Assuming 70% adherence, 

screening of national 

population with colonoscopy 

every 10 years would require 

4.8 million screening/ 

surveillance colonoscopies in 

2000 (3 times the current 

volume of 1.6 million) 

Fair 

Demand scenario: screening the unscreened by various strategies 

Seeff et al., 2004202 

Modeling 

US population 

Additional available 

capacity estimates from 

Seeff et al., 2004 

Current unscreened 

population at average 

risk estimated using 

census data, adjusted 

for estimates of 

persons at higher risk 

and using screening 

rates from NHIS 

41.8 million persons 

unscreened 

Using 100% of additional 

available capacity, it would 

take 3 years at current 

screening patterns or 6 years 

using 100% FS or FOBT/FS 

to screen the unscreened 

Good 

population 

Using 100% of additional 

available capacity, it would 

take 5 years to screen the 

unscreened population with 

colonoscopy 

For a program using FOBTs, 

there would be enough 

capacity for the necessary 

follow-up colonoscopies 

within 1 year 

Current volume of 

colonoscopies 

conducted by 

gastroenterologists 

estimated by analysis of 

CORI database 

Demand estimated by 

Markov model; number 

of lifetime 

colonoscopies and FSs 

per patient for the US 

population under 

various scenarios 

Assuming 70% adherence, a 

colonoscopy screening 

strategy every 10 years 

would require an incremental 

number of 5.0 million 

colonoscopies (above 

baseline of 1.69 million per 

year) 

Assuming 100% adherence, 

a colonoscopy screening 

strategy every 10 years 

would require an incremental 

number of 6.3 million 

colonoscopies (above 

baseline of 1.69 million per 

year) 

Fair (volume 

estimates) 

Good 

(demand 

estimates) 

146 
Table 47. National estimates of ability of current volume or additional available capacity of flexible 

sigmoidoscopy or colonoscopy to meet projected demand for endoscopy, by different demand scenarios 

(continued) 

Author, Year Data Collection or 

Study Design Data Inputs for Model Description to Quality 

Setting Capacity/Volume Project Demand Results Rating 

Demand scenario: Increasing demand for CT colonography 

Ladabaum et al., 2005 

(2887)201 None Current and projected 

demand (in various 

Assuming 75% uptake, 

demand for colonoscopy 

Good 

screening scenarios) would be 6.2 million CTC and 

estimated by Markov 3.3 million colonoscopies if all 

Hur et al., 2004199 Current colonoscopy 

model 

Demand for 

screening by CTC 

Current volume: Fair 

volume estimated from colonoscopy predicted 6.47 million colonoscopies 

Secondary data analysis CORI database from mathematical 1.98 million colonoscopies for 

and modeling model screening (29%) 

US population If CTC used as primary 

modality for CRC screening, 

assuming 55% adherence to 

screening and 67% of 

screening is CTC, in the 

initial 5-year period after 

implementation of CTC, 

demand for colonoscopy 

could decrease by 1.78 

million; partially offset by 0.34 

million follow-up 

colonoscopies for CTC with 

positive findings (10 mm 

Pickardt et al., 2008203 Current volume of CTC Markov model used to 

polyp) 

Assuming 60% compliance Fair 

estimated from estimate demand for with screening, 67% of 

Modeling secondary data on CT the US population screening is CTC, and rise in 

scanners in the US number and percentage of 

US population CT scanners performing CTC 

(from n = 718/10% to n = 

10,000/90%), there is 

sufficient capacity to screen 

10 years from now in a 

steady-state scenario 

CORI, Clinical Outcomes Research Initiative; CRC, colorectal cancer; CT, computed tomography; CTC, computed tomography colonography; 

FOBT, fecal occult blood test; FS, flexible sigmoidoscopy; MDs, physicians; NHIS, National Health Interview Survey. 

All six studies used census data with specific refinements (such as omitting persons who are 

above average risk or who may be too “sick” for screening) as inputs into mathematical models 

to estimate current and projected demand. The types of refinements of population estimates, the 

types of models, and the assumptions regarding demand (most importantly, what percentage of 

the population would be included in a future screening scenario) used to construct the models 

varied widely among the studies. The percentage of the population included in future screening 

scenarios ranged from 40 percent to 100 percent. 

Overview of results. Six studies provided some data on the ability of current capacity or 

volume to meet projected demand under various steady-state scenarios. For each scenario, we 

present estimates of projected demand from across all studies and compared these levels of 

projected demand with estimates of current capacity from across all studies. 

In the first scenario, in which 75 percent of the US population is screened by FOBT alone, 

the projected demand for colonoscopy is 3.8 million.201 Based on estimates of current capacity 

147 
from across the studies, current capacity is likely sufficient to meet the demand for colonoscopy. 

If a similar proportion (70 percent to 75 percent) of the US population is screened using either 

FS or combined FS/FOBT, an estimated 6.9 million to 10 million FSs and 2.7 million to 4.7 

million colonoscopies are needed. Current volume of FS is not sufficient, but current capacity, 

including estimates of additional available capacity, is likely sufficient to meet projected 

demand; current volume of colonoscopy is sufficient. Finally, if 70 percent of the US population 

is screened by a colonoscopy alone, the projected demand is 4.8 million to 8.1 million 

colonoscopies. Current volume is not sufficient to meet the projected demand, but current 

capacity, including additional available capacity, may be sufficient. All of these estimates 

represent steady-state scenarios; none of these models incorporated current estimates of the 

unscreened. 

In the single study that modeled the extent to which available capacity was sufficient to 

screen the unscreened population, the investigators determined that, using 100 percent of 

additional available capacity, it would take 3 years at current screening patterns, 6 years using 

100 percent FS or FOBT/FS, or 5 years using 100 percent colonoscopy to screen the unscreened 

population. 

Detailed assessment, FOBT screening scenario. One good-quality study used a Markov 

model to estimate endoscopic demand under various screening demand scenarios.201 It reported 

that if 75 percent of the US population were screened by FOBT alone, 3.8 million colonoscopies 

would be needed for followup of abnormal FOBTs, for post polypectomy surveillance, or for 

diagnosis of symptomatic CRC or followup after CRC treatment. 

Detailed assessment, FS screening scenario. Two studies, one rated good and one rated fair, 

reported similar estimates on the number of FS needed if a large proportion of the population 

were screened with FS every 5 years. One study, which used a Markov model to estimate 

endoscopic demand under various screening demand scenarios, found that if 75 percent of the 

US population were screened by FS alone, 10.0 million FSs and 2.7 million colonoscopies would 

be needed annually.201 The NCI study also used a microsimulation model that incorporated 

population estimates and assumptions about test performance to estimate demand for FS.195 They 

found that if 70 percent of the US population were screened by FS every 5 years, the number of 

FS procedures required annually would be “almost 10 million,” which is approximately twice 

their estimate of FS current volume. 

Detailed assessment, FOBT/FS screening scenario. Two studies, both rated good, reported 

on the number of colonoscopies needed if a proportion of the population were screened with FS 

every 5 years and FOBT every year. One used a Markov model to estimate endoscopic demand 

under various screening demand scenarios and found that if 75 percent of the US population 

were screened by FOBT/FS, 6.9 million FSs and 4.7 million colonoscopies would be needed 

annually.201 The other study, which estimated current volume using the CORI database and 

demand based on a Markov model, found that, assuming 70 percent adherence to a FOBT/FS 

screening strategy, an incremental number of 1.2 million colonoscopies would be needed above 

the baseline of 1.69 million per year (total of ~2.9 million screening colonoscopies).200 

Detailed assessment, colonoscopy screening scenario. Three studies, two rated good and one 

rated fair, reported on projected demand if 70 percent to 75 percent of the US population were 

screened by colonoscopy alone. The study that estimated demand scenarios found that if 75 

percent of the US population were screened by colonoscopy alone, 8.1 million screening 

colonoscopies would be needed annually.201 The study that estimated current volume using the 

CORI database and demand based on a Markov model, found, assuming 70 percent adherence to 

a colonoscopy screening strategy every 10 years, that an incremental number of 5.0 million 

colonoscopies would be needed above a baseline of 1.69 million per year (total of 6.69 million 

148 
screening colonoscopies).200 The NCI study found that if 70 percent of the US population were 

screened by colonoscopy every 10 years, the number of screening colonoscopy procedures 

required annually would be 4.8 million (which was three times the estimated current volume in 

that study).195 

None of these studies gave estimates of additional available capacity. Of the two studies that 

estimated current volume in addition to projected demand, projected demand far exceeded 

current volume. This pattern suggested that a colonoscopy screening strategy for a large 

proportion of the population could not be supported. However, if the estimates of current 

available capacity from Seeff and colleagues202 are taken into account (an additional 8.2 million 

colonoscopies per year), the current endoscopy infrastructure might possibly support a 

colonoscopy strategy of this sort. 

Detailed assessment, screening the unscreened by various scenarios. One study was unique 

in that it modeled the ability of additional available capacity (rather than current volume) to 

screen all current average-risk unscreened persons in the US population (rather than modeling 

various screening strategies for the entire US population).202 This study, rated good quality, 

modeled the time needed to screen the current unscreened US population (41.8 million persons) 

by various strategies. This study found that, using 100 percent of additional available capacity, it 

would take 3 years at current screening patterns or 6 years using 100 percent FS or FOBT/FS to 

screen the average-risk unscreened population. Using 100 percent of additional available 

capacity, it would take 5 years to screen the unscreened population with colonoscopy. 

Detailed assessment, increasing demand for CT colonography (CTC) scenario. Three 

studies, one rated good and two rated fair, modeled increasing demand for CTC. Two had as 

outcomes the effect on demand for colonoscopy;199,201 the third asked whether projected CTC 

capacity is sufficient to meet projected CTC demand.203 The good-quality study using a Markov 

model to estimate endoscopic demand under various screening demand scenarios reported, 

assuming 75 percent uptake, that demand for colonoscopy would be 6.2 million if all screening 

was done by CTC.201 The fair-quality study, estimated capacity from data from the CORI 

database and modeled demand based on a mathematical model. Assuming 55 percent adherence 

to any kind of screening and 67 percent of screening being CTC (overall 37 percent utilization of 

CTC), these investigators reported that, in the initial 5-year period after implementation of CTC, 

demand for colonoscopy could decrease by 1.78 million. This would be partially offset by 0.34 

million follow-up colonoscopies for CTC with positive findings.199 Because assumptions for 

utilization of CTC varied widely between the two studies, they cannot be directly compared. 

The third study asked a very different question: whether projected capacity of CTC is 

sufficient to meet projected demand.203 The authors assumed 60 percent compliance with any 

kind of screening, 67 percent of screening being CTC, and a rise in the number and percentage of 

CT scanners performing CTC from 718 and 10 percent to 10,000 and 90 percent. Given these 

factors, they concluded that the nation will have sufficient capacity to screen 10 years from now 

in a steady-state scenario. 

KQ 5: Effective Approaches for Monitoring Use and Quality 

of Colorectal Cancer Screening 

Valid data on the use and quality of CRC screening are central to efforts to decrease 

morbidity and mortality from CRC in the United States. To understand the current status of CRC 

screening and the effects of interventions to increase the use and quality of screening, we must 

have both valid measures of CRC screening use and quality of those services and effective 

149 
monitoring approaches to obtain data on these measures. KQ 5 examines the approaches for 

monitoring use and quality of CRC screening in populations and the effectiveness of these 

monitoring approaches. 

As a starting point for defining an effective approach for monitoring use and quality of CRC 

screening, we identified frameworks for public health monitoring (or surveillance) systems from 

both the United States and Canada.47,205 To avoid confusion over the term ‘surveillance’, we 

have opted to use it to describe surveillance colonoscopy (colonoscopy for patients who have had 

a previous colonic polyp (and, usually, polypectomy)) and have replaced the term ‘surveillance’ 

with regard to data collection related to CRC test use to the term ‘monitoring’. Therefore, all 

discussions about data systems will be referred to as those that monitor use or quality. These 

frameworks provide complementary lists of characteristics or attributes of monitoring systems 

that are applicable to the design of an ideal approach to monitoring CRC use and quality. 

Although the notion of a monitoring system may be more common for infectious diseases than 

for cancer or other chronic conditions, these frameworks are intended to be applicable to both 

chronic and infectious diseases. Also, although monitoring systems are often thought of in terms 

of disease incidence and mortality (rather than health care utilization or health care quality), 

public health is beginning to monitor risk factors and preventive services such as CRC screening, 

not just diseases. 

The frameworks that we identified 

Table 48. Characteristics of public health monitoring provide a comprehensive and logical way to systems that contribute to effectiveness 

think about evaluating existing approaches 

to monitoring the use and quality of CRC 

screening, and they provide guidance for the 

design of optimal monitoring approaches. 

Table 48 describes characteristics or 

attributes of monitoring systems that the 

review team found applicable to CRC 

screening; it also gives working definitions 

adapted from the US and Canadian 

frameworks. In addition to these 

characteristics, the frameworks described 

more global system performance 

characteristics of usefulness, effectiveness, 

and/or efficiency. The items in this table are 

considered to contribute to overall system 

performance, including effectiveness; in 

Characteristic Working definition 

Data quality Completeness and validity of the data in 

the system 

Timeliness Interval between occurrence of an event 

and reporting of the event 

Acceptability Willingness of persons and organizations 

to participate in the monitoring system 

Simplicity Structure and ease of operation 

Flexibility Ability of the system to accommodate 

changes in operating conditions or 

information needs 

Compliance Degree to which a system complies with 

all relevant legislation, regulations, and 

policies 

Stability Reliability (ability to collect, manage and 

provide data properly without failure) and 

availability (ability to be operational when 

it is needed) of the monitoring system 

Cost Indirect and direct costs 

Adapted from Health Canada, 2004205 

addition to these characteristics, a critical 

component of effectiveness as defined in one framework is how well the system achieves its 

intended results.205 

In our literature search, all the articles identified relevant to KQ 5 pertained only to the first 

system characteristic, data quality. We found no articles that measured other characteristics of a 

monitoring system or that compared any of these characteristics between systems. Also, we 

found no articles that addressed the monitoring of quality of CRC screening, just monitoring of 

CRC screening use. 

Specifically, most of the articles that we identified evaluated the accuracy of measures of 

CRC screening as obtained from various data sources (self-report, medical record review, or 

administrative data);35,39-40,206-207 these studies add to the evidence from a recent systematic 

review208 and other literature that appeared before our time period of included articles. We also 

150 
found one study that described an attempt to solve one of the barriers in using administrative data 

to determine screening rates, that of distinguishing screening from diagnostic endoscopies,209 and 

two studies that evaluated novel means of combining more than one data source to produce 

hybrid measures of CRC use.35,210 

Other than establishing the quality of data on CRC screening use by evaluating the accuracy 

of measures of CRC screening as obtained from various data sources (self-report, medical record 

review, or administrative data), we found no other studies that measured or compared any of the 

other characteristics of monitoring systems (such as acceptability or cost). Thus, although this 

body of literature gives indications of data quality of the various sources for monitoring CRC 

use, it provides little evidence to inform the larger questions of what monitoring approaches, 

overall, are effective. 

Our overall summary and strength of evidence tables for studies addressing this KQ are 

presented at the beginning of this section. The remainder of this section provides a more detailed 

assessment of the individual studies that informed our conclusions and our assessment of the 

strength of evidence. 

KQ 5 Overall Summary and Strength of Evidence 

In Table 49, our overall grades of the strength of evidence appear in the far right column; 

grades for key domains to determine the strength of evidence are in the intermediate columns. In 

assessing research specific to KQ 5 about effectiveness of varying approaches to monitoring 

CRC use and quality, we found varying grades between low and high depending for different 

aspects of this KQ. The grade can be interpreted as the confidence that the evidence reflects the 

true effect. For example, a grade of low means that further research is likely to change the 

confidence in the estimate of effect, and is likely to change the estimate. 

Overall, the evidence suggests that self-reported rates of CRC screening are higher than rates 

obtained by medical record review or administrative data (high strength of evidence). 

Nevertheless, rates of agreement between self-reported CRC screening and information found in 

medical records or administrative data are at least moderate (moderate strength of evidence), 

indicating that all three methods are generally appropriate for monitoring CRC screening use. 

The evidence suggests, although strength of evidence is low, that concordance among data 

sources is higher for rates of endoscopy screening than for rates of FOBT screening. Evidence 

was insufficient for using algorithms to determine whether a colonoscopy identified in 

administrative data was conducted for screening or for diagnostic purposes. The evidence also 

suggests that using a hybrid method (administrative data plus medical record review or self 

report of CRC screening) will increase the reported prevalence of screening, but whether validity 

is increased is not known (low strength of evidence). 

151 
Table 49. Strength of evidence for approaches to monitoring effectiveness of CRC screening use and quality 

Risk of Bias Overall 

Number of studies; strength of 

Number of subjects Design/Quality Consistency Directness Precision Results evidence 

Effective approaches of monitoring use and quality of CRC screening 

No study NA NA NA NA NA Insufficient 

Validity of self-report, administrative data, and medical record review ot measure CRC screening use: 

Comparing prevalence of CRC screening rates by various sources 

Hall et al., 2004206 Low No Direct NR Self-reported CRC High 

Schenck et al., 200739 inconsistency screening rates are 

Schenck et al., 200840 4 Cross higher than rates 

Fiscella et al., 2006207 sectional/3 obtained by medical 

Schneider et al., Good, 1 Fair records or 

200835 administrative data 

4: 190,358 

Validity of self-report, administrative data, and medical record review to measure CRC screening use: 

Concordance among data sources for CRC screening measures 

Hall et al., 2004 206 Low Inconsistency Direct Precise Concordance Moderate 

Schenck et al., 200739 present between selfSchenck et al., 200840 3 Cross reported CRC 

Fiscella et al., 2006207 sectional/3 Good screening and 

medical record or 

3: 4,165 administrative data 

was at least 

moderate 

(agreement >70% or 

kappa > 0.4) 

Validity of self-report, administrative data, and medical record review to measure CRC screening use: 

Concordance among data sources for CRC screening measures, by screening test 

Hall et al., 2004 206 Low Inconsistency Direct Precise Concordance Low 

Schenck et al., 200739 present between self-report 

Schenck et al., 200840 2 Cross and medical record 

sectional/2 Good or administrative 

2: 2,691 data is higher for 

endoscopy than for 

FOBT 

Distinguishing screening from diagnostic endoscopy using an algorithm for administrative data 

Haque et al., 2005209 Moderate No Direct NR Algorithms have not Low 

El-Serag et al., 200664 inconsistency been able to 

2 Cross distinguish between 

1: 523 sectional/2 Fair diagnostic and 

screening 

endoscopic exams 

in administrative 

data 

Ability of a hybrid method (using administrative data and self-report) to increase validity of measurement 

Pignone et al., 2009210 Moderate Consistent Direct NR Hybrid methods will Insufficient 

Schneider et al., 

200835 2 Cross 

increase reported 

prevalences of CRC 

sectional/2 Fair screening, but 

2: 194,952 whether validity is 

increased is 

unknown. 

CRC, colorectal cancer; FOBT, fecal occult blood test; NA, not applicable; NR, not reported. 

Overall study characteristics. We found seven studies of good or fair quality that reported 

data on effectiveness of approaches to monitor use of CRC screening.35,39-40,206-207,209-210 Three 

studies that were specific to validation of a set of survey questions developed by the National 

Cancer Institute211 were not included as they did not meet our inclusion criteria.212-214 Four 

152 
studies took place within a managed care setting or a health plan35,206,209-210 and three included 

Medicare patients seen in non-managed care settings.39-40,207 All were cross-sectional studies that 

compared two or more data sources on CRC screening to evaluate the accuracy of the method of 

interest. 

Overall study results. Included studies addressed only data quality; we found no studies that 

described or compared other monitoring system attributes. Although none of the three data 

sources can be considered a gold standard, all three appear to be generally appropriate for 

monitoring CRC screening status. However, self-reported rates of CRC screening are 

consistently higher than rates obtained from either medical records or administrative data. 

The included studies reported a wide range of measures of concordance (agreement and/or 

kappa statistic, which accounts for agreement expected by chance) comparing CRC screening 

measures from the three data sources.35,39-40,206-207 In most studies that report accuracy of selfreport for FOBT, any endoscopy, or any testing, concordance between self-report and medical 

record or administrative data was at least moderate (agreement greater than 70 percent or kappa 

greater than 0.40). Concordance appears to be higher for endoscopy than for FOBT. 

One problem with using administrative data is that distinguishing screening from diagnostic 

examinations is difficult; the single study reviewed was not able to use an algorithm to do so 

effectively.209 Two studies demonstrated that administrative claims will underreport CRC 

screening rates (by showing that survey or medical record review will pick up additional 

screenings that were false negatives in the claims data), but they do not demonstrate conclusively 

that measuring CRC screening rates using hybrid methods is a more valid or a more effective 

approach overall.35,210 

The following chapter is divided into three sections, based on the purpose of the studies. The 

first category includes studies that compared two or three types of data sources to evaluate data 

validity.35,39-40,206-207 The second category includes one study, which evaluated the use of a 

computer algorithm to distinguish diagnostic from screening endoscopy in administrative data.209 

The final category includes two studies that used combinations of administrative, medical record, 

and survey data to assess the accuracy of these novel ways of CRC screening measurement.35,210 

As with other KQs, tables in this section list studies by quality (good followed by fair) and 

then alphabetically by last name of the first author of the article(s). Appendix C§§ presents the 

evidence tables with the details of these studies. 

Validity of Self-Report, Administrative Data, and Medical Record 

Review to Measure CRC Screening Status 

Study characteristics. We found five studies of good or fair quality that reported data on the 

validity of various data sources of CRC screening rates.35,39-40,206-207 The single study rated fair 

did not report detail on methods to ensure valid medical record abstraction.35 

Two studies took place within a managed care setting or a health plan;35,206 of these, one 

included all plan members 51 years or older,35 and one used slightly different age cutoffs for men 

and women (45 and older for men and 55 and older for women).206 Three studies evaluated 

measures of CRC screening in Medicare populations.39-40,207 Of these, two included Medicare 

patients ages 55 to 8039-40 and the third included Medicare patients 65 and older.207 

§§ Appendixes and evidence tables cited in this report are available at 

http://www.ahrq.gov/downloads/pub/evidence/pdf/crcuse/crcuse.pdf. 

153 
All studies were cross-sectional studies that compared two or more data sources on CRC 

screening to evaluate the accuracy of the method of interest. One study compared self-report of 

CRC screening with medical record review only,206 whereas the remaining studies examined all 

three sources of data—self-report, medical records, and administrative data. One study used 

secondary data from the Medicare Current Beneficiary Survey (MCBS);207 the remaining four 

studies involved surveys of patients for self-reported CRC screening history. 

In general, these studies asked questions about several types of screening tests, followed by 

questions about the time frame when the tests occurred. Two studies reported that their questions 

were modeled after national studies such as the NHIS and BRFSS.35,206 Studies generally 

compared the prevalences of CRC screening as measured by different data sources and/or 

reported agreement, defined as the percentage of persons for whom the two data sources agreed 

and a kappa statistic. 

Overview of results. Results of the studies were of two main types (Tables 50 and 51). In 

the five studies that compared prevalence rates of CRC screening from self-report with 

prevalence rates from medical record data or administrative data, the rates of FOBT, FS, and 

colonoscopy are generally higher as measured by self-report than by medical record data or by 

administrative data (Table 50). In the two studies that compared medical record data with 

administrative data, both in Medicare patients, administrative data may have slightly higher 

prevalence rates than those reported by the medical records. The range of concordance among 

the studies that compared the three data sources (Table 51) was wide. In most studies that 

reported accuracy of self-report for FOBT (two studies), for endoscopy (two studies), and for any 

testing (one study), concordance between self-report and medical record or administrative data 

was at least moderate (agreement greater than 70 percent or kappa greater than 0.40). 

Concordance appears to be higher for endoscopy than for FOBT. 

Detailed assessment. In the first study, conducted by CDC staff and authors from three 

health plans (in Georgia, Minnesota, and North Carolina), participants were recruited who had 

been enrolled in their plan for at least 5 years and were ages 45 years and older (men) or 55 and 

older (women).206 The investigators stratified the sample by site and sex and oversampled 

African-Americans members. Participants were recruited by letter and telephone; the cooperation 

rate was 64.8 percent. Investigators examined participants’ medical records for the previous 5 

years. The study found that a higher percentage of respondents received testing when measured 

by self-report than by medical record audit (Table 51). The authors calculated a kappa statistic 

and used a cutoff of 0.40, above which indicates at least fair agreement (by the authors’ 

definition of poor less than 0.40; fair to good of 0.40-0.75; and excellent of > 0.75). They 

concluded that agreement was fair to good for FS and colonoscopy among most groups and poor 

for FOBT in two or three HMOs (Table 51). 

In the second study, researchers compared Medicare claims data with self-report from the 

MCBS of having received an FOBT, FS, or colonoscopy among white, African-American, or 

Hispanic enrollees who were at least 65 years, did not reside in a long-term care facility, and 

were not enrolled in a Medicare HMO.207 The survey was conducted in 2000; the study did not 

mention the time frame for administrative claims review nor distinguish screening from 

diagnostic procedures in either data source. Only race-specific prevalences were reported, as the 

goal of the study was to examine disparities in screening rates as measured by different data 

sources. In this study, rates of screening were as follows: white, self-report 38 percent; white, 

claims 30.1 percent; minority, self-report 34.8 percent; and minority, claims 20.4 percent (Table 

50). The kappa score measuring agreement between self-report and claims was 0.37 for whites 

and 0.19 

154 
Table 50. Assessing validity of CRC screening measures: Comparing prevalence of CRC screening rates by 

various data sources 

Author, Year 

Study Design 

Population 

Setting 

Sample Size 

Quality Study Aim Data Sources Results 

Hall et al., 2004206 Examine the Medical record review to Among 3 demographic groups in 3 health plans 

accuracy of self- determine whether any (data combined), the percentage of respondents 

Cross-sectional report of CRC of the tests had been who received testing was higher when measured 

screening among recorded within 5 years by self-report (survey) than by medical record 

Three HMOs in members of 3 review 

Georgia, Minnesota, health plans Survey of sampled 

and North Carolina health plan members for Black men; white/other men; women: 

self-reported CRC FOBT 

N: 363 (black men), screening history Survey 22.2; 20.3; 25.9 

847 (white/other Medical record review 11.6; 9.5; 14.1 

men), 920 (women) 

FS 

Good Survey 38.4; 42.0; 50.0 

Medical record review 29.6; 30.6; 34.1 

Colonoscopy 

Survey 13.7; 14.6; 15.7 

Medical record review 8.1; 11.1; 9.6 

Endoscopy 

Survey 44.4; 49.8; 58.6 

Medical record review 34.4; 37.8; 39.8 

Fiscella et al., 

2006207 Determine 

whether estimates 

Prevalence of receipt of 

FOBT, FS, or 

CRC screening 

of racial colonoscopy as White: 

Cross-sectional disparities in measured by: Survey 38.0 

receipt of CRC Administrative 30.1 

Medicare screening and Self-report (survey) of 

beneficiaries, age other preventive having any of the tests Minority: 

≥ 65, community 

dwelling who were 

included in the 

procedures differ 

between selfreport and 

in the last year (MCBS) 

(indication was not 

specified) 

Survey 34.8 

Administrative 20.4 

MCBS; white race Medicare claims 

compared with 

minority (Hispanic 

plus non-Hispanic 

African American) 

data Medicare claims, 

including both screening 

and diagnostic codes 

(administrative data) 

N: 1,474 

Good 

155 
Table 50. Assessing validity of CRC screening measures: Comparing prevalence of CRC screening rates by 

various data sources 

Author, Year 

Study Design 

Population 

Setting 

Sample Size 

Quality Study Aim Data Sources Results 

Schenk et al., 

200739 Compare 

ascertainment of 

Prevalence of receipt of 

FS (in last 4 years) or 

Prevalence of endoscopy in the past year 

endoscopy colonoscopy (in last Overall: 

Cross-sectional screening among 5 years) as measured Survey 50.1 

3 data sources: by: Administrative 44.9 

Medicare self-report, Medical record review 42.3 

beneficiaries, white Medicare claims, Self-report in 2002 on a 

or African-American and medical telephone survey; FS By sociodemographic characteristics: 

between the ages of record review vs. colonoscopy were 

55-80, no history of described and queried Age 55-64; 65-74; 65-80 

CRC, in 10 urban for separately; Survey 50.8; 52.4; 44.0 

counties in North respondents were Administrative 35.6; 43.9; 50.7 

Carolina who had asked if the exam was Medical record review 32.2; 40.7; 50.0 

responded to a part of a check up or 

telephone survey in because of a problem All African Americans; all whites; all women, all 

2002 on CRC men: 

screening Medicare claims: Survey 40.9; 52.9; 46.8; 55.3 

inpatient, physician, and Administrative 41.7; 45.9; 43.6; 47.0 

N: 561 hospital outpatient Medical record review 42.4; 42.2; 42.7; 41.6 

claims from 1/1998­

Good 12/2002 (screening vs. Less than high school; high school diploma; more 

diagnostic exams were than high school: 

distinguished) Survey 28.7; 46.9; 59.8 

(administrative data) Administrative 39.4; 45.9; 45.8 

Medical record review 38.3; 41.8; 43.6 

Medical record review: 

record abstraction 

between 1/1998 and 

12/2002 from the 

primary care provider 

(or a provider identified 

by an algorithm) and for 

some, the MD 

performing the 

procedure. Exams were 

classified as screening if 

the test was conducted 

for screening or as part 

of a well-adult visit, and 

all others were 

classified as diagnostic 

156 
Table 50. Assessing validity of CRC screening measures: Comparing prevalence of CRC screening rates by 

various data sources 

Author, Year 

Study Design 

Population 

Setting 

Sample Size 

Quality Study Aim Data Sources Results 

Schenk et al., 

200840 Compare 

ascertainment of 

Prevalence of receipt of 

FOBT as measured by: 

Prevalence of FOBT in the past year 

FOBT among Overall: 

Cross-sectional 3 data sources: Self-report in 2002 on a Survey 28.7 

self-report, telephone survey: at- Administrative 21.2 

Medicare Medicare claims, home FOBT described Medical record review: 19.4 

beneficiaries, white and medical and respondents asked 

or African-American record review whether they had ever By sociodemographic characteristics: 

between the ages of had a test and the date 

55-80, no history of of most recent test; Age 55-64; 65-74; 65-80 

CRC, in 10 urban respondents were Survey 35.2; 27.9; 28.4 

counties in North asked if the exam was Administrative 19.3; 21.0; 23.6 

Carolina who had part of a check up or Medical record review: 19.3; 19.8; 19.6 

responded to a because of a problem 

telephone survey in All African Americans; all whites; all women, all 

2002 on CRC Medicare claims: billing men 

screening for FOBT (diagnostic or Survey 32.0; 27.8; 30.6; 25.9 

screening codes) from Administrative 18.8; 22.4; 25.5; 15.3 

N: 561 1/1998 to 12/2002 Medical record review: 12.5; 21.9; 21.7; 16.7 

(administrative data) 

Good Less than high school; high school diploma; more 

Medical record review: than high school 

record abstraction Survey 26.6; 26.0; 31.6 

between 1/1998 and Administrative 20.2; 20.4; 22.8 

12/2002 (distinguishing Medical record review: 19.1; 16.3; 22.4 

in-office tests from 

home kits where 

possible) 

Schneider et al., 

200835 Describe a field 

test of a screening 

Prevalence of specific 

CRC screening tests or 

Among members in each of 5 health plans, the 

percentage of respondents who received testing 

measure included any CRC screening was generally higher when measured by selfCross-sectional in the HEDIS compared among: report than by administrative data 

Survey data 

5 health plans in the Administrative data By health plan A; B; C; D; E: 

US Hybrid of administrative 

and medical record FOBT 

N: 189,193 review data Survey 25.4; 26.3; 20.5; 21.8; 25.1 

administrative data Administrative 23.6; 15.0; 31.1; NA; 24.7 

and 1,250 survey 

respondents FS 

Survey 29.7; 39.6; 33.9; 33.6; 30.6 

Fair Administrative 14.2; 17.9; 18.4; 15.3; 15.4 

Colonoscopy 

Survey 19.9; 39.0; 33.6; 33.7; 40.7 

Administrative 12.8; 12.1; 9.4; 10.5; 14.2 

157 
200835 

Table 50. Assessing validity of CRC screening measures: Comparing prevalence of CRC screening rates by 

various data sources 

Author, Year 

Study Design 

Population 

Setting 

Sample Size 

Quality Study Aim Data Sources Results 

Schneider et al., 

(continued) 

Any CRC screening 

Survey 53.2; 69.7; 55.0; 62.1; 66.2 

Administrative 41.5; 38.6; 47.1; 27.3; 44.4 

Hybrid 41.5; 53.5; 52.6; 38.8; 45.6 

Survey respondents were more likely than 

nonrespondents to have evidence of CRC 

screening (62.7% vs. 46.5%; P < 0.001) 

CRC, colorectal cancer; FOBT, fecal occult blood test; FS, flexible sigmoidoscopy; HEDIS, Health Plan Employer Data and Information Set; 

HMO, health maintenance organization; MCBS, Medicare Current Beneficiary Survey; N, number; NA, not applicable. 

Table 51. Assessing validity of CRC screening measures: Concordance among data sources for CRC 

screening measures 

Author, Year 

Study Design 

Population 

Setting 

Sample Size 

Quality Study Aim Data Sources Results 

Hall et al., 2004206 Examine the Medical record review to Concordance between self report and medical 

accuracy of self- determine whether any of records is reported as the range of the nine 

Cross-sectional report of CRC the tests had been values (for each of 3 demographic groups in 

screening among recorded within 5 years each of 3 HMOs) for each of the following 

Three HMOs in members of 3 items: 

Georgia, health plans Sampled health plan 

Minnesota, and members were asked FOBT 

North Carolina whether they had ever 

been tested and date of 

Agreement: 0.78-0.86* 

Kappa: 0.23-0.62† 

N: 363 (black most recent test 

men), 847 FS 

(white/other men), Agreement: 0.63-0.89 

920 (women) Kappa: 0.31-0.77 

Good Colonoscopy 

Agreement: 0.86-0.94 

Kappa: 0.30-0.69 

Any endoscopy 

Agreement: 0.61-0.92 

Kappa: 0.30-0.83 

158 
Table 51. Assessing validity of CRC screening measures: Concordance among data sources for CRC 

screening measures 

Author, Year 

Study Design 

Population 

Setting 

Sample Size 

Quality Study Aim Data Sources Results 

Fiscella et al., 

2006207 Determine whether 

estimates 

Prevalence of receipt of 

FOBT, FS, or colonoscopy 

Concordance between self-report and 

administrative data (measured by kappa score) 

of racial disparities as measured by: for CRC screening 

Cross-sectional in receipt of CRC 

screening and Self-report of having any White 0.37 

Medicare other preventive of the tests in the last year 

beneficiaries, age procedures differ (MCBS) (indication was Minority 0.19 

≥ 65, community 

dwelling who were 

included in the 

between self-report 

and Medicare 

claims data 

not specified) 

Medicare claims, including 

MCBS; white race both screening and 

compared with 

minority (Hispanic 

diagnostic codes 

(administrative data) 

plus non-Hispanic 

African American) 

N: 1,474 

Good 

Schenk et al., 

200739 Compare 

ascertainment of 

Prevalence of receipt of 

FS (in last 4 years) or 

Measures of concordance for endoscopy use 

endoscopy colonoscopy (in last 5 Administrative to medical record review 

Cross-sectional screening among 3 years) as measured by: Agreement: 95 (93-97) 

data sources: self- Kappa: 0.89 (0.81-0.98) 

Medicare report, Medicare Self-report in 2002 on a 

beneficiaries, white claims, and telephone survey; FS vs. 

or African- medical record colonoscopy were Self-report to medical record review 

American between review described and queried for Agreement: 70 (66-73) 

the ages of 55-80, separately; respondents Kappa: 0.39 (0.31-0.47) 

no history of CRC, were asked if the exam 

in 10 urban was part of a check up or Self-report to administrative 

counties in North because of a problem Agreement: 70 (66-74) 

Carolina who had Kappa: 0.40 (0.32-0.49) 

responded to a Medicare claims: inpatient, 

telephone survey physician, and hospital Agreement regarding test type (FS or 

in 2002 on CRC outpatient claims from colonoscopy) 

screening 1/1998-12/2002 

(distinguished screening Claims to medical record review: 93 (88-97) 

N: 561 vs. diagnostic exams) Self-report to medical record review: 82 (75­

(administrative data) 89) 

Good Self-report to claims: 77 (70-85) 

Agreement regarding test purpose (screening 

or diagnostic): 

Administrative to medical record review: 52 

(43-61) 

Self-report to medical record review: 65 (55­

74) 

Self-report to administrative: 29 (20-36) 

159 
200739 

Table 51. Assessing validity of CRC screening measures: Concordance among data sources for CRC 

screening measures 

Author, Year 

Study Design 

Population 

Setting 

Sample Size 

Quality Study Aim Data Sources Results 

Schenk et al., 

(continued) 

Medical record review: 

record abstraction 

between 1/1998 and 

12/2002 from the primary 

care provider (or a 

provider identified by an 

algorithm) and for some, 

the MD performing the 

procedure; exams were 

classified as screening if 

the test was conducted for 

screening or as part of a 

well-adult visit, and all 

others were classified as 

diagnostic 

Schenk et al., 

200840 

Cross-sectional 

Medicare 

beneficiaries, white 

or AfricanAmerican between 

the ages of 55-80, 

no history of CRC, 

in 10 urban 

counties in North 

Carolina who had 

responded to a 

telephone survey 

in 2002 on CRC 

screening 

N: 561 

Good 

Compare 

ascertainment of 

FOBT among 3 

data sources: selfreport, Medicare 

claims, and 

medical record 

review 

Prevalence of receipt of 

FOBT as measured by: 

Self-report in 2002 on a 

telephone survey; 

description of at-home 

FOBT provided, and 

persons asked whether 

they had ever had a test 

and the timing of most 

recent test 

Medicare claims: billing for 

FOBT (diagnostic or 

screening codes) from 

1/1998 to 12/2002 

(administrative data) 

Medical record review: 

record abstraction 

between 1/1998 and 

12/2002 (distinguishing inoffice tests from home kits 

where possible) 

Measures of concordance for FOBT 

Administrative to medical record review 

Agreement: 82 (79-85) 

Self-report to medical record review 

Agreement: 70 (66-74) 

Self-report to administrative 

Agreement: 67 (63-71) 

Sensitivity analyses included: excluding claims 

of FOBT on day of medical visit; including all 

medical record review of FOBTs (likely 

including in-office, single card FOBTs with 

digital rectal exams); did not appreciably 

change the measures 

CRC, colorectal cancer; FOBT, fecal occult blood test; FS, flexible sigmoidoscopy; HEDIS, Health Plan Employer Data and Information Set; 

HMO, health maintenance organization; MCBS, Medicare Current Beneficiary Survey; N, number.
 

*Agreement is the percentage of persons for whom the two data sources agree.
 

†Kappa statistic is a measure of agreement that accounts for agreement expected by chance. 

for minorities. The authors also calculated ORs for reporting a procedure in the absence of a 

claim, or vice versa. Minorities were more likely to report receipt of CRC screening in the 

absence of a claim (OR, 1.92, 95% CI, 1.32-2.79), with little change after adjustment for age, 

gender, income, educational level, health status, proxy response, and supplemental insurance. 

Having a claim for CRC testing in the absence of self-report did not differ by race or ethnicity. 

160 
The North Carolina Quality Improvement Organization (the Carolinas Center for Medical 

Excellence) did two studies to evaluate all three data sources, namely self-report, medical 

records, and administrative data, for measuring CRC screening among Medicare patients. One 

study evaluated these data sources for measuring endoscopy39 and the other for measuring 

FOBT.40 Included persons were Medicare beneficiaries who were white or African-American, 

between the ages of 55 and 80, with no history of CRC, and residing in 10 urban counties in 

North Carolina who had responded to a telephone survey in 2002 on CRC screening. 

The survey provided explanations of the FOBT, FS, and colonoscopy procedures, attempting 

to distinguish in-office FOBT from home FOBT, and also asked respondents if the examination 

was part of a check up or because of a problem. For the medical record review, the investigators 

linked patients to a medical provider (to complete the medical record review) using a hierarchical 

approach. First, they asked survey respondents to name a provider; if that provider could not be 

located or if the response to the question was missing or unusable, they used a claims algorithm 

to identify a likely primary care provider. If the abstracted record from the primary care provider 

did not contain information about an endoscopy noted in claims data, then the claims data were 

used to identify the physician who had performed the procedure and the researchers then 

abstracted the medical record from this physician as well. Specific to the endoscopy study, 

medical record review captured whether the test was done for screening or diagnostic reasons. 

Specific to the FOBT study, data on the four most recent FOBTs were abstracted, including the 

reason for the test and the nature of the test (sending three samples collected at home to the 

laboratory, a digital rectal examination [DRE] with a FOBT performed in the office, or not 

specified). For the claims data, Medicare inpatient, physician, and outpatient claims for 

endoscopies were obtained for the 5-year period 1/1/1998 through12/31/2002. Screening and 

diagnostic codes were available for both FOBT and endoscopic procedures. 

In the first study, self-reported FS within the past 4 years or colonoscopy in the past 5 years 

was compared with evidence in claims or medical record review that the procedure had been 

done. Prevalence of endoscopy screening was highest when measured by self-report (50.1 

percent) followed by claims data (44.9 percent) and medical record review (42.3 percent); 

sociodemographic subgroups differed somewhat in these percentages (Table 50). The authors 

also found high agreement (95 percent; kappa = 0.89) between claims and medical records and 

good agreement (70 percent) between self-report and medical records and self-report and claims 

(kappa = 0.39-0.40) (Table 51). Also, all three data sources were able to distinguish the type of 

procedure done (FS versus colonoscopy), based on agreement between the data sources (77 

percent to 93 percent), but none showed reliable levels of agreement regarding whether the test 

was screening or diagnostic (Table 51). 

The second North Carolina study evaluated measurement of FOBT in the past year in a 

similar fashion.40 Overall, the level of self-report of FOBT was higher (28.7 percent) than the 

level measured by claims (21.2 percent) or medical record review (19.4 percent); again, 

subgroups differed somewhat in these rates (Table 50). Lower rates of agreement were found 

among the three data sources for FOBT (67 percent to 82 percent) than for endoscopy (Table 

51). The authors concluded that no data source could be established as providing valid 

information about FOBT among Medicare enrollees. 

The final study, which we rated fair quality, was a field test of a National Committee for 

Quality Assurance (NCQA) performance measure.35 The investigators randomly selected 200 

persons age 51 or older from each of five health plans who had been enrolled continuously for at 

least 2 years and who lacked evidence of recent CRC screening; they conducted both a survey 

and medical record review. For the survey, they selected an additional 400 persons per plan were 

selected (for a total of 600 per plan). The response rate to the survey, which asked about CRC 

161 
screening and time frames in which they occurred, was 48.1 percent. CRC screening status was 

ascertained from administrative data, from the survey, and from a hybrid method of 

administrative records plus medical record review (for overall, not test-specific, screening 

status). Among members in each plan, the percentages of respondents who received testing were 

generally higher when measured by self-report than by administrative data (Table 50). Of note, 

survey respondents were more likely than nonrespondents to have evidence of CRC screening 

(62.7 percent versus 46.5 percent; P < 0.001). 

Distinguishing Screening from Diagnostic Endoscopy Using an 

Algorithm for Administrative Data 

Study characteristics. Two studies evaluated an algorithm’s ability to distinguish between 

screening and diagnostic endoscopy (Table 52).64,209 We rated both studies as fair quality, the 

first because of the limitations in their methods used to ensure validity of the medical record 

review data209 and the second because of limited reporting of the outcome.64 One study took 

place in a sample of patients from one HMO;209 the second in VA patients from one medical 

center.64 

Overview of results. Algorithms that use concomitant diagnostic codes to distinguish 

whether an endoscopy is screening or diagnostic have not been able accurately to distinguish the 

two types of endoscopies. 

Detailed assessment. In the first study, using data from a large staff-model HMO, the 

algorithm classified an endoscopy as diagnostic if administrative data included certain conditions 

in the year before the examination or either specific signs or symptoms or an FOBT within 45 

days before the examination. All participants in this HMO ages 50 to 70 who had been 

continuously enrolled for 5 years and who had completed an endoscopy during that time were 

eligible for the study. The investigators selected a stratified random sample of 220 participants 

based on the algorithm’s classification of the endoscopy (for each of FS and colonoscopy, 30 

diagnostic and 80 screening). They then reviewed medical charts and classified the examination 

as diagnostic based on the chart review if it was a follow-up to a previous abnormality or if clearcut conditions or signs were present, using the same list as the algorithm. The algorithm had a 

low sensitivity for diagnostic endoscopies (48.1 percent for FS and 23.8 percent for 

colonoscopy). Overall, the agreement was better for sigmoidoscopies (kappa = 0.76) than for 

colonoscopies (kappa = 0.44). 

In the second study, national VA datasets were used to identify all FOBT, FS, DCBE, and 

colonoscopy procedures performed in the VA between 1998 and 2003. All FOBTs were 

designated screening. All FS, DCBE, and colonoscopy procedures were classified as screening, 

followup, or diagnostic based on an algorithm considering diagnoses in the year before the 

procedures. A random sample of 303 medical records from a single VA hospital was reviewed 

by two gastroenterologists blinded to the designated status given by the algorithm. Agreement 

between the reviewers was achieved in 92 percent of cases; they resolved differences by 

discussion. Results from the medical record review were compared with the designation by the 

algorithm; only sensitivity and specificity for the algorithm’s ability to identify screening 

colonoscopy were reported, 70.1 percent and 71.l6 percent, respectively. 

162 
Table 52. Comparison of classification of diagnostic versus screening procedure using an algorithm for 

administrative data 

Author, Year 

Study Design 

Population 

Setting 

Sample Size 

Quality Study Aim Data Sources Results 

Haque et al., 

2005209 Develop an 

automated data 

Administrative data: 

endoscopies were 

FS 

Sensitivity of diagnostic classification: 48.1 

algorithm identified using ICD-9 Specificity of diagnostic classification: 12.1 

Cross-sectional designed to and CPT-4 codes and 

distinguish were classified as Sensitivity of screening classification: 87.9 

Large HMO in screening and diagnostic vs. screening Specificity of screening classification: 51.9 

southern California diagnostic using presence of a list 

endoscopy; the of diagnostic codes and Kappa 0.76 

N: 220 algorithm was signs and symptoms 

compared with (that would suggest the Colonoscopy 

Fair medical record procedure were Sensitivity of diagnostic classification: 23.8 

review as the diagnostic) Specificity of diagnostic classification: 15.6 

gold standard 

Medical record review to Sensitivity of screening classification: 84.4 

establish whether Specificity of screening classification: 76.2 

diagnostic or screening 

exam Kappa: 0.44 

El-Serag et al., 

200664 Investigate 

whether 

Administrative data: 

Inpatient and outpatient 

Colonoscopy 

Sensitivity of screening classification: 70.1 

colonoscopy databases searched for Specificity of screening classification: 71.6 

Cross-sectional use increased codes indicating FS, 

disproportionat FOBT, DCBE, and 

A single Veterans ely in the VA colonoscopy 

Administration system and 

hospital changes in Indications for tests 

rates of FS, were classified using an 

N:303 DCBE, and algorithm based on 

FOBT use diagnoses in the one 

Fair year before the test 

Medical record review to 

establish whether 

diagnostic or screening 

exam 

CPT, Current Procedural Terminology; DCBE, double contract barium enema; FOBT, fecal occult blood test; FS, flexible sigmoidoscopy; HMO, 

health maintenance organization; ICD, International Classification of Diseases; N, number. 

Evaluating Novel Ways to Combine Data Sources for CRC Screening 

Measurement 

Study characteristics. We found two studies that evaluated novel ways to combine data 

sources to improve routine measurement of CRC screening use.35,210 We rated these studies as 

fair quality; one lacked data to assess the outcome fully,210 and the other did not ensure valid 

medical record abstraction.35,209 Both studies took place within a managed care or health plan 

setting. One study attempted to improve measurement of CRC screening use by augmenting 

administrative data with survey data, and the second by augmenting with medical record data. 

Although one study compared the rates of CRC screening from the hybrid method with both 

administrative and survey data for the entire sample, 35 the second could compare its rates only 

163 
with administrative data, 210 because the survey was conducted only among persons for whom no 

evidence of CRC screening had been found in the administrative data. 

Overview of results. In both studies, reported rates of CRC screening increased when 

administrative data were combined with either survey data or medical record data. The 

investigators provided no evidence (other than reporting prevalences) of the validity of these 

hybrid methods. 

Detailed assessment. In one study, the researchers recruited a sample of members in a single 

health plan (Aetna), ages 52 to 80, from 32 primary care practices in Florida and Georgia that 

were taking part in a randomized trial of a CRC decision aid and practice-level academic 

detailing.210 Participants with no evidence of screening in the claims data were surveyed about 

completion of any CRC tests and the time frame (within 1 year, 1 to 5 years, 5 to 10 years, or 

more than 10 years). The researchers excluded from their calculations persons with evidence of 

medical exclusions in the claims data and persons found to be at above-average risk on the 

survey. Insurance claims were examined for evidence of FOBT within 1 year, FS or barium 

enema within 5 years, or colonoscopy within 10 years. The indication for the test was not 

specified in the survey and the authors do not discuss using screening versus diagnostic codes in 

analyzing the claims data. The authors reported that the prevalence of current screening among 

average-risk persons by claims data was 27 percent; combining claims data and survey data and 

accounting for survey nonresponse, they estimated that 47 percent to 59 percent of member 

patients were actually up-to-date. 

In the NCQA field test, described above, the investigators constructed samples in five 

geographically dispersed health plans of persons both with and without administrative claims 

evidence of CRC screening.35 Among those with such evidence, the researchers selected a 

sample for the survey; of those without evidence in the claims, they selected a sample for both 

medical record review and the survey. The hybrid method combined administrative and medical 

record data to provide an estimate based on both. Among members in each of the five health 

plans, the percentages of respondents who received testing were generally higher when measured 

by the hybrid method than by administrative data, but they were lower than those recorded by 

survey data (Table 53). 

164 
Table 53. Evaluating novel ways to combine data sources for CRC screening measurement 

Author, Year 

Study Design 

Population 

Setting 

Sample Size 

Quality Study Aim Data Sources Results 

Pignone et al., 2009210 

Cross-sectional 

Aetna members ages 

52-80 from 32 primary 

care practices in Florida 

and Georgia taking part 

in a randomized trial of 

a CRC decision aid and 

practice-level academic 

detailing 

N: 5,759 age-eligible in 

claims and 1,595 survey 

responders 

Fair 

Evaluate the 

independent 

and 

combined 

yield of 

claims and 

direct 

survey for 

identifying 

CRC 

screening 

among 

average-risk 

health plan 

beneficiarie 

s 

Insurance claims for 

FOBT within 1 year, 

FS 

or barium enema 

within 5 years, or 

colonoscopy within 10 

years (indication not 

specified) 

Survey of persons 

with 

no evidence of 

screening in claims 

data to ask about 

completion of any of 

the same CRC tests 

and time frame 

(within 1 year, 1-5 

years, 5-10 years, or 

> 10 years) 

Prevalence of current screening among persons 

without medical exclusions, by claims data alone: 

27% 

Prevalence combining claims data plus selfreported data (not including nonresponders to the 

survey): 47% 

Prevalence combining claims data plus selfreported data (assuming nonresponders were 

screened at the same rate as average-risk 

responders): 59% 

Schneider et al., 200835 

Cross-sectional 

5 health plans in the US 

N: 189,193 in 

administrative data and 

1,250 survey 

respondents 

Fair 

Describe a 

field test of 

a screening 

measure 

included in 

HEDIS 

Prevalence of specific 

CRC screening tests 

or any CRC 

screening compared 

among: 

Survey data 

Administrative data 

Hybrid of 

administrative and 

medical record review 

data 

Among members in each of 5 health plans, the 

percentage of respondents who received testing 

was generally higher when measured by self-report 

than by administrative data 

The percentage of persons who received testing as 

measured by the hybrid method generally fell 

between percentages based on survey or 

administrative data 

Plans A; B; C; D; E 

Any CRC screening by: 

Survey 53.2; 69.7; 55.0; 62.1; 66.2 

Administrative 41.5; 38.6; 47.1; 27.3; 44.4 

Hybrid 41.5; 53.5; 52.6; 38.8; 45.6 

Survey respondents were more likely than 

nonrespondents to have evidence of CRC 

screening (62.7% vs. 46.5%; P<0.001) 

CRC, colorectal cancer; FOBT, fecal occult blood test; FS, flexible sigmoidoscopy; HEDIS, Health Plan Employer Data and Information Set; N, 

number. 

165 

Chapter 5. Discussion 

The RTI International-University of North Carolina Evidence-based Practice Center (RTIUNC EPC) prepared this report for the National Institutes of Health (NIH) State-of-the-Science 

Conference on Enhancing Use and Quality of Colorectal Cancer Screening, which is scheduled 

for February 2010. This chapter summarizes and discusses the findings of our review of peerreviewed literature concerning improving the appropriate use and quality of colorectal cancer 

(CRC) screening. 

We adopted three outcomes on which to focus: use of CRC screening, patient-physician 

discussions about CRC screening, and quality of CRC screening. The screening tests included in 

our review are the at-home fecal occult blood test (FOBT), flexible sigmoidoscopy (FS), 

colonoscopy, and double contrast barium enema. We attempted to find studies on the uses of 

tests recently introduced to clinical practice for CRC screening, including the fecal 

immunochemical test, fecal DNA testing, and computed tomographic colonoscopy, but found no 

studies concerning the trends in use and quality of these tests. We further examined 

“appropriate” use in terms of three constructs: underuse, overuse, and misuse. This report 

presents findings from a systematic review of literature from January 1998 to September 2009 of 

four key questions (KQs): 

KQ 2: What factors influence the use of CRC screening? 

KQ 3: What strategies are effective in increasing the appropriate use of CRC screening and 

followup? 

KQ 4: What are the current and projected capacities to deliver CRC screening and 

surveillance at the population level? 

KQ 5: What are the effective approaches for monitoring the use and quality of CRC 

screening?
 

We also present background information on trends in the use and quality of CRC screening (KQ 

1), relying on national studies and relevant articles from our extensive search for KQs 2 through 

5. Finally, we comment on research needs (KQ 6). 

Results for KQ 2 are largely descriptive. KQ 3, KQ 4, and KQ 5 are more analytic; each asks 

for information about the effectiveness of different approaches and an interpretation of 

comparisons presented in study analyses. For this reason, we provide strength of evidence 

evaluations for KQ 3, KQ 4, and KQ 5 but not for KQ 2; the strength of evidence tables and 

overall grades can be found in Chapter 4 in the relevant sections. We refer readers to Chapter 2 

for methods for rating the quality (internal validity, or risk of bias) of individual studies and for 

grading the overall strength of evidence for specific groups of studies. 

In the remainder of this chapter, we first give an overall summary of our findings, for all 

KQs. We then consider some implications of our findings and discuss the limitations of the 

review. Finally, we present suggestions for future research (KQ 6). 

Summary of Findings 

As summarized in Table 54, our extensive literature review for KQ 1 found many problems 

of underuse, overuse, and misuse of CRC screening. To guide our systematic reviews for KQs 2 

167 
Table 54. Summary of the evidence and strength of evidence grades by key question 

Strength 

of 

Evidence 

Key Question Grades* Conclusions 

KQ 1: What are the 

recent trends in the use 

and quality of colorectal 

cancer screening? 

NA† (1) Both CRC screening and patient-physician discussions of CRC 

screening are underused. Self-reported screening rates by national 

surveys, which are likely to be overestimates of actual screening, in 2005­

2006 were about 50- 60%; an even smaller percentage of people had had 

a discussion about CRC screening with their primary care physician. Less 

certain, but likely, is underuse of surveillance colonoscopy (colonoscopy 

for patients who have had a previous colonic polyp [and, usually, 

polypectomy]) in some individuals who have previously had a 

polypectomy for an advanced adenoma. 

(2) Screening is also overused, insofar as people who are unlikely to 

benefit may be screened. This includes people over age 85 or people with 

severe comorbidities. Surveillance colonoscopy is also probably 

overused. Polypectomy for polyps less than 5 mm (for which benefit is 

uncertain but increased risk is clear) may also be considered an overuse 

category. 

(3) Problems of misuse also arise. These include use of in-office rather 

than home FOBT, nonreturn of FOBT cards, lack of adequate followup of 

positive FOBT results, and colonoscopy that does not reach the cecum, 

that has too rapid withdrawal time, or that misses important lesions. 

(4) We found no reliable data among studies included in this review on 

the trends of use or quality of fecal immunochemical test (FIT), fecal DNA 

testing, or computed tomographic colonoscopy. 

KQ 2: What factors NA‡ (1) Several factors are consistently associated with reduced CRC 

influence the use of screening (i.e., P < 0.05 or confidence intervals that do not overlap or 

colorectal cancer 

screening?║ include 1.0). They include: 

• low patient income1-2,42,46,107,114,120,122-123,126,130,150-151,156 

• low education21,46,151 

• being uninsured21,46,56,113-114,128,151,160 

• being Hispanic1,21,46,111,115-116,119-120,126,141,147,151,163 or Asian1-2,114,147 

• not being acculturated into the United States (i.e., English language 

proficiency, US or foreign born, years living in US) 1-2,118,120­

122,141,147,149,161 

• having less/reduced access to care, such as lack of a regular 

source of primary care1-2,21,42,46,56,107-108,111,120,128,130,133­

134,151,157,163,215 or no visits in previous year to 

provider2,21,46,55,107,126,132,137,151,158,166 

• lack of a physician recommendation to be screened. 

21,46,55­

57,107,111,136,142,148,153,159 

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Table 54. Summary of the evidence by key question (continued) 

Key Question 

KQ 2: What factors 

influence the use of 

colorectal cancer 

screening? 

(continued) 

Strength of 

Evidence 

Grade* 

NA§ 

Conclusions 

(2) Factors positively associated with CRC screening (i.e., P < 0.05 or 

confidence intervals that do not overlap or include 1.0) include 

• having private insurance21,46,107,113-114,124,128,151 

• being non-Hispanic white,21,46,106,120,125,128,138,142,151 

• completing a higher levels of education21,46,151 

• participating in regular screenings for other cancers21,42,46,108,122­

123,133-134,151,156,158,215 

• having a family history of CRC or personal history of another 

cancer2,21,42,46,107,122,134,151,158 

• having regular access to care, having effective provider-patient 

communication56,135,140,154,167 

(3) We only found one study each that examined the association between 

screening and either specific physician characteristics or patient-physician 

connectedness, thereby providing insufficient evidence to draw 

conclusions about these relationships. 

(4) We found six studies that examined the association of system 

variables with CRC screening.66,110,127,139,143,173 Several single system 

variables were associated with higher screening rates; the only variable 

associated with higher screening in more than one study was use of 

nonphysician staff in assisting patients with understanding or completing 

screening. 

(5) We found no studies that examined factors associated with overuse or 

misuse of CRC screening or surveillance. 

KQ 3: Which strategies 

are effective in 

increasing the 

appropriate use of 

colorectal cancer 

screening and followup? 

High 

High 

(1) Interventions that provide patient reminders lead to small to moderate 

increases in CRC screening (four studies, with absolute increases of 5.0 

percent, 5.9 percent, 11.7 percent, and 15.0 percent).175,182-183,186 

(2) Four studies of small media (educational print or video messages) to 

increase CRC screening show no benefit.177-178,181,185 

Low (3) Evidence concerning decision aids to increase screening is mixed. 

With two of three studies showing benefit, some types of decision aids 

may be effective for increasing screening (14.0 to 23.0 percentage point 

increases in screening rates reported in the two positive studies).175,182-183 

Low (4) Two studies on group education interventions to increase CRC 

screening showed no benefit.184-185 

High (5) One-on-one interactions, especially intensive contact with patients, 

increase screening rates, sometimes to a large degree;85,179-180 observed 

percentage point increases included 14.6 percentage points for FOBT 

completion,85 20.9 percentage points for any CRC test,180 and 41.9 

percentage points for FOBT completion.179 

High (6) Interventions that provided a means for eliminating structural barriers, 

such as improving access to CRC screening tests or reducing language 

barriers,85,175,179,183,187 demonstrated the highest impact on screening 

rates overall (ranging from an increase of 14.6 to 41.9 percentage points). 

169 
Table 54. Summary of the evidence by key question (continued) 

Key Question 

Strength of 

evidence Conclusions 

KQ 3: Which strategies Low (7) Use of small media with or without decision aids vs. no intervention 

are effective in 

increasing the 

appropriate use of 

colorectal cancer 

screening and followup? 

(continued) 

Low 

increases discussions with providers (25.1 percentage point difference 

from one study).177 

(8) One study found providing reminders to physicians to be slightly 

effective in raising appropriate surveillance colonoscopy rates;188 one 

study found no difference in CRC screening among patients whose 

providers received reminders.186 

High (9) Five studies on system-level interventions162,189-193 consistently 

reported increased screening rates for patients for whom a patient 

navigator or prevention care manager (PCM) was provided or when 

organizational processes and procedures were changed to help patients 

obtain timely CRC screening. 

Insufficient (10) We found no evidence to determine the efficacy of any intervention to 

reduce overuse or misuse of CRC screening, 

KQ 4: What are the 

current and projected 

capacities to deliver 

Low (1) Current volume of FS is 2.8-4.9 million and additional available 

capacity is 6.7 million.195-196 

colorectal cancer 

screening and 

surveillance at the 

Low (2) Current volume of colonoscopy is1.6-6.6 million and additional 

available capacity is 8.2 million.195-196,199-200 

population level? Low (3) Based on one study’s estimates of additional available capacity, 

current capacity for colonoscopy is sufficient for a screening program by 

FOBT.195-196,199-201 

Low (4) Based on one study’s estimates of additional available capacity, 

current capacity for FS is sufficient for a screening program by FS 

alone.195-196,201 

Low (5) Based on one study’s estimates of additional available capacity, 

current capacity for colonoscopy is sufficient for a screening program by 

FS alone.195-196,199-201 

Low (6) Based on one study’s estimates of additional available capacity, 

current capacity for FS is sufficient for a screening program by 

FOBT/FS.195-196,201 

Low (7) Based on one study’s estimates of additional available capacity, 

current capacity for colonoscopy is sufficient for a screening program by 

FOBT/FS.196,199-201 

Low (8) Based on one study’s estimates of additional available capacity, 

current capacity for colonoscopy is sufficient for a screening program by 

colonoscopy.195-196,200 

Low (9) If the United States were to adopt a colonoscopy-only approach to 

CRC screening, colonoscopy capacity would need to be substantially 

increased or at least 5 years would be needed to do the “catch-up” 

screening required to screen people who have not yet been screened.202 

170 
Table 54. Summary of the evidence by key question (continued) 

Strength of 

Key Question evidence Conclusions 

KQ 5: What are the 

effective approaches for 

monitoring the use and 

quality of colorectal 

cancer screening? 

High 

Medium 

Low 

Low 

Insufficient 

(1) Self-reported rates of CRC screening are higher than rates obtained 

from either medical records or administrative data. 

(2) Concordance between self-reported CRC screening and medical 

record or administrative data was at least moderate (agreement > 70.0 

percent or kappa > 0.4). 

(3) Concordance between self-report and medical record or administrative 

data is higher for endoscopy than for FOBT. 

(4) Algorithms have not been able to distinguish between diagnostic and 

screening endoscopic exams in administrative data. 

(5) Hybrid methods will increase reported prevalences of CRC screening, 

but whether validity is increased is unknown. 

CRC, colorectal cancer; DNA, Deoxyribonucleic acid; FOBT, fecal occult blood test; FIT, fecal immunochemical test; mm, millimeters; NA, not 

applicable; P, probability; US, United States. 

* Strength of evidence grades and definitions (see Chapter 2 for details): High=High confidence that the evidence reflects the true effect. Further
 

research is very unlikely to change our confidence in the estimate of effect. Moderate=Moderate confidence that the evidence reflects the true 

effect. Further research may change our confidence in the estimate of effect and may change the estimate. Low=Low confidence that the evidence 

reflects the true effect. Further research is likely to change our confidence in the estimate of effect and is likely to change the estimate. 

Insufficient=Evidence either is unavailable or does not permit estimation of an effect.
 

† KQ 1 is a background question that does not employ exhaustive systematic review methodology. Thus, strength of evidence grades are not 

applicable for this topic. 

‡ KQ 2 was also not done through an exhaustive systematic review methodology, so we did not grade strength of evidence for this topic.
 

§Strength of evidence graded for KQ 3, KQ 4, and KQ 5 only.
 

║ Those that are mutable are in bold font to highlight areas where interventions and policies could be implemented to improve screening rates.
 

to 5, we developed an analytic framework (Figure 1, Chapter 2). Our review helped us to specify 

better the important factors in the analytic framework that may be helpful in considering ways to 

improve the appropriate use and quality of CRC screening. 

From the patient’s point of view in Figure 1, we found that access to health care in general 

(including having health insurance and a regular source of primary care) is a necessary 

predisposing factor to CRC screening. Our KQ 2 review found specifically that having health 

insurance and a regular physician are strongly associated with higher levels of CRC screening. 

People without health insurance and a regular source of primary care have very low screening 

rates. This is not surprising; the nature of CRC screening, and the absence of a national program 

outside of primary care to deliver screening to the uninsured, is such that having a regular source 

of primary care is essential to improving CRC screening rates. 

As shown in the analytic framework (Figure 1), however, access to care alone is insufficient 

to guarantee high levels of screening. After patients have access to care, they still need a simple 

and reliable mechanism by which to engage with physicians and/or others in the health care 

system to understand the idea of screening and the pros and cons of screening strategies. Few 

health care systems build such discussions into routine care, as shown by our KQ 1 finding of 

suboptimal numbers and quality of discussions about CRC screening. With such a varied range 

of screening strategies for CRC screening, this lack of a mechanism to promote and assist patient 

understanding and choice is a major barrier to appropriate use. An important finding in our KQ 2 

review is that unscreened patients did not know about the need for CRC screening, and “just 

didn’t think about it.” The great majority of patients with physicians who recommend screening 

171 
actually complete screening. Ideally, this recommendation would be accompanied by a 

reasonable discussion of screening options. 

Helping patients understand CRC screening entails more than giving information in a onesided, noninteractive manner. Our KQ 3 review found that small media messages with such 

materials as brochures alone were ineffective in increasing appropriate screening. Certain 

decision aid designs may be a useful approach in assisting patients to understand the pros and 

cons of screening and to make informed decisions about which screening strategy is right for 

them. The evidence to date on the effectiveness of decision aids is insufficient to determine the 

best design and delivery models; more research is needed. 

In developing systems that can reliably help patients understand CRC screening and choose 

an appropriate screening strategy, several groups of disadvantaged patients need special 

attention. Patients who are not fluent in the English language, patients whose culture differs from 

that of the prevailing US medical culture, and (probably) patients with low levels of health 

literacy need specially designed approaches to help them understand CRC screening. Our KQ 2 

review showed the screening rates of Hispanic people and of people not acculturated into the 

United States to be significantly lower than those of non-Hispanic whites and/or those born or 

living in the United States for longer periods of time. 

Because of the few studies of the association between physician characteristics or health care 

systems and CRC discussions/screening, we cannot say whether certain types of physicians, or 

certain types of systems within which physicians work, are or are not more associated with 

appropriate screening. Some evidence indicates (KQ 2) that system factors such as involving 

nonphysician staff and having electronic medical records may be associated with appropriate 

screening. 

Although access to care (e.g., a regular source of primary care that one visits at least 

annually), together with health insurance coverage for screening, combined with patient 

understanding and physician recommendation of screening, increases appropriate screening for 

many people, though some groups still need further assistance with completing screening. This 

step, between patient decision and appropriate test use, appears straightforward in the analytic 

framework (Figure 1); we found it is often more complex than depicted in this framework. 

Because CRC screening strategies require people to carry out unusual procedures of 

preparation and testing, and then to navigate the medical system to complete screening, assisting 

people in the details of completing screening is sometimes necessary to reach high rates of 

appropriate screening. Our KQ 3 review found that, in some populations, employing more 

intensive one-on-one approaches, eliminating or reducing structural barriers for patients, and 

making overall system changes successfully increase appropriate screening. These sometimes 

intensive approaches are likely not necessary for all populations, although reducing barriers and 

streamlining and simplifying the screening process are likely to be helpful for all. 

We developed our analytic framework and conducted our review with the understanding that, 

from the major guideline groups, a range of appropriate options for CRC screening exists. In 

contrast to this view, however, the United States might decide to favor a strategy of preferring an 

initial colonoscopy over other strategies. Our review of KQ 4 indicates a considerable degree of 

uncertainty about whether the nation has existing—or even latent—capacity to meet the need in 

this latter assumption. That is, we cannot conclude that the country can either conduct “catch-up” 

screening of people who have not been screened or to continue steady-state screening and the 

resulting surveillance for the longer term. Thus, if the United States were to embark on an initial 

172 
colonoscopy-preferred strategy, and if the above approaches to increasing screening use were 

effective, then inadequate capacity to screen the eligible population is a real possibility. 

Almost all the literature we found and reviewed for KQ 2 and KQ 3 focused on the problem 

of underuse of CRC screening. Despite our finding in KQ 1 that CRC screening discussions are 

also underused, we uncovered little evidence concerning factors associated with, or interventions 

to improve, underuse of screening discussions. 

KQ 1 also showed considerable problems with overuse and misuse of CRC screening. No 

studies reviewed in KQ 2 examined factors associated with overuse of screening; no studies 

reviewed in KQ 3 examined interventions to reduce overuse of CRC screening. Similarly, little 

of the literature for KQ 3 examined interventions to reduce misuse in screening. 

As shown in our analytic framework (Figure 1), an important (and probably necessary) factor 

between decisions about screening and appropriate use (minimizing overuse and misuse as well 

as underuse) is monitoring. Our review in KQ 1 found several monitoring systems for self-report 

of CRC screening use; these include the National Health Interview Survey (NHIX) and the 

Behavioral Risk Factor Surveillance System (BRFSS). However, few systems monitor overuse 

and misuse. We found no systems in the United States for reducing overuse and no corrective 

steps to minimize misuse. We found no direct evidence about monitoring to review in KQ 5. 

Table 54 highlights our primary findings and conclusions from KQs 1 to 5. 

We have adapted general recommendations for monitoring systems (Table 55) to show what 

types of data systems might be considered. Some initial systems are being started and could be 

encouraged and expanded. A national program of breast and cervical cancer screening and a 

mammography consortium both provide important information to monitor screening for these 

cancers. A complementary approach might be to expand data collection in the Surveillance, 

Epidemiology and End Results (SEER) program areas to include screening rates and even 

misuse data; such information might then be correlated with incidence and pathology data from 

SEER. 

173 
Table 55. Features of an ideal monitoring system for CRC screening use and quality 

Characteristics of 

Monitoring System Important Features of an Ideal System for CRC screening 

Data quality: • Includes the following variables: 

Use (both underuse and – overall screening rates by test type 

overuse) – inappropriate screening rates owing to age or severe comorbidities 

–	 percentage of persons with whom adequate screening discussions are held 

–	 percentage of FOBT cards that are returned 

–	 percentage of persons who attend their screening endoscopy appointment 

–	 results of screening tests and the percentage of persons with positive tests who 

receive complete diagnostic evaluation 

–	 percentage of persons with appropriate and inappropriate screening and/or followup 

–	 number/rate of polypectomies for colonic lesions < 5 mm 

Data quality: • Includes the following colonoscopy indicators216-217 

Appropriate use or misuse – cecal intubation rates 

–	 adenoma detection rates for adenomas ≥10 mm 

– colonoscopy withdrawal time 

–	 percentage of colonoscopies with adequate bowel preparation 

– complication rates 

Data quality: • Links screening monitoring to pathology and tumor registry or SEER data 

Additional elements • Represents entire US population 

Acceptability • Has a high participation rate of practices 

• Has a low burden to report data 

Compliance • Meets all legal standards for data sharing 

Costs • Is low cost 

•	 Is sustainable without research funding 

Usefulness • Is designed to meet users’ needs. For example, has goals to evaluate quality of 

screening or to document outcomes of screening in a community-based setting. 

FOBT, fecal occult blood test; SEER, Surveillance Epidemiology and End Result. 

Implications of This Review 

Although we found a gradual increase in CRC screening over the past 10 to 12 years, this 

increase still leaves the nation at a lower screening rate for CRC than for breast (or even 

prostate) cancer.194 Finding interventions to increase appropriate CRC screening has clearly been 

challenging, perhaps more so than for other cancers. Perhaps because of the complexity (and 

even invasiveness) of the CRC tests, or because of the problem of having to choose among 

screening strategies, many people have not understood the need for CRC screening, and others 

have not been able to complete screening. Medical practice systems have often been inadequate 

in informing patients, discussing their questions, and assisting them in the complexities of 

completing CRC screening. 

Our summary of our findings highlights certain aspects of our analytic framework (Figure 1) 

and points to a logical series of steps to improve appropriate CRC screening. The first step 

concerns access to health care, including having health insurance and a regular source of primary 

care, as a necessary predisposing factor. The nature of CRC screening is that a physician (or 

nonphysician medical staff) must be involved in the decision to screen and in the completion of 

testing. 

After access to care, the second step is to find ways for all patients to engage in a discussion 

at some level. The design and intensity of the discussion will depend on the patient’s prior 

understanding of CRC screening and the health care system. Such discussions take place with a 

trained health educator (e.g., physician or nonphysician staff), perhaps with an effective and 

174 
tested decision aid, and focus on the pros and cons of CRC screening and the various screening 

options open to the patient. This interaction would need to be different for people with special 

circumstances, such as lack of fluency in English or lack of acculturation to the United States, 

than for most patients. 

The third step in this progression is to simplify procedures for completing CRC screening for 

everyone. This includes providing proactive assistance to people from disadvantaged groups to 

complete screening after the screening decision has been made. 

The further implications of this review are related to the implications for interventions to 

increase appropriate CRC screening use and quality (including reducing underuse, overuse, and 

misuse) and to three cross-cutting themes that underlie our findings: access to CRC screening; 

communication about CRC screening; and the organization of CRC screening. These three issues 

are among the strongest, potentially modifiable barriers to improving the use and quality of CRC 

screening. 

Interventions to improve screening. Although we found high strength of evidence and 

positive effects for patient reminders, one-on-one interactions, eliminating structural barriers, 

and overall system changes as interventions to improve screening, still not clear is whether any 

set of interventions would effectively increase appropriate screening rates to high levels across 

the country. The health system may or may not have the ability to implement these interventions 

on a broad scale within medical practices and for the general population. To implement and 

maintain these interventions properly, an effective monitoring and feedback system (KQ 5) is 

needed. These systems are not in place in most primary care practices or health care systems. 

How to overcome the focus in US medical care on nonpreventive care, and how to overcome 

the time and cost barriers to implementing and maintaining the systems within busy primary care 

practices, is also unclear. For example, incentives to primary care practices for improving CRC 

screening rates may or may not work. Partly because of the lack of positive incentives and the 

required time and effort from primary care practices, the durability of interventions that initially 

seem successful may be questionable. Another important issue is how interventions to improve 

CRC screening integrate with other medical practice systems. 

Finally, the cost-effectiveness of the sometimes intensive interventions to gain sometimes 

small increases in screening is also unknown. Until these more fundamental issues are resolved, 

the question of whether widespread implementation of any interventions will have a large, 

sustained effect at reasonable cost (including time and effort of the patient, the physician, and the 

medical practice) remains unanswered. 

Access to CRC screening. A critical underlying issue in this literature is access to care, a 

necessary precursor to access to CRC screening. Among the more striking findings from our 

review of factors associated with lower rates of CRC screening (KQ 2) is that people without 

health insurance, people with no source of usual care, people with no recent physician visits, and 

people with lower income status have quite low CRC screening rates. Improved communication 

and medical care organization can be effective only for people who are connected to a primary 

care provider. 

Communication about CRC screening. One positive finding of this report is the overall 

importance of communication specific to CRC screening between medical staff and patients in 

improving appropriate CRC screening (i.e., reducing underuse, overuse, and misuse). CRC 

screening requires a great deal of patient understanding and effort (e.g., knowing which tests to 

take and when, and how to get them done). Communicating such information to patients and 

guiding them in making decisions specific to their medical and family history all take time. To 

175 
make appropriate decisions about individually optimal screening, to carry out the preparation and 

follow-through correctly, and to obtain screening at recommended intervals all require patient 

knowledge, motivation, and assistance from medical personnel. When few CRC discussions take 

place (KQ 1), when many eligible patients do not know that they should be screened (KQ 2), 

when medical personnel make few recommendations for screening (KQ 2), when many people 

do not receive periodic health examinations (at which some time might be devoted to discussions 

of CRC screening [KQ 2]), and when few intensive one-on-one interventions exist to assist 

patients to decide, prepare, and follow-through (KQ 3), suboptimal screening rates should not be 

surprising. 

An instructive case study for the importance of communication is the situation of Hispanic 

and Asian populations in the United States, especially because these groups have low rates of 

CRC screening (KQ 2). Although access to care certainly accounts for some of the disparity in 

screening rates for Hispanics, even when studies adjust for access, multiple good-quality studies 

using national population-based data show that screening rates for Hispanics or Asians continue 

to remain below those of non-Hispanic whites.1,46,111,120,141,147,151 This finding suggests that other 

factors, such as language and cultural differences, are also likely to be important determinants of 

screening. 

Determining whether differences in CRC screening test use are mediated primarily through 

differences in language or differences in cultural beliefs about health and prevention is 

challenging, since language use is often a central part of the definition of acculturation.121,149 

Determining whether lower screening rates in Hispanics or Asians is driven mainly by cultural 

beliefs, by possible distrust of the medical health system, or by language is important. If the 

differences in screening test use reflect true differences in informed choices not to have 

screening based on culturally mediated values and preferences, then some of the difference in 

screening test use may be appropriate. However, accumulating evidence suggests that language 

and possibly literacy barriers contribute to lack of knowledge about the risk that CRC poses and 

about the potential benefits of screening. Poor communication, at the level of the health care 

system as a whole, at the community level, and at the level of the patient-physician interaction, 

clearly contributes to low CRC screening rates in racial and ethnic groups. Language and literacy 

barriers likely lead to even poorer communication among subpopulations that prefer to obtain 

health information in a language other than English. 

Organization of CRC screening and monitoring. CRC screening in the United States 

requires the involvement of primary care physicians. Most receive no regular feedback on their 

CRC screening rates, as might occur in the Veterans Health Administration (VA) or other 

integrated health care system. Few medical practices involve nonphysician office staff in 

discussing CRC screening with patients; few reach out to patients who have not been screened or 

who miss screening appointments. As suggested by the VA’s success with CRC screening (KQ 

1), by the association of use of nonphysician staff with higher CRC screening rates (KQ 2), and 

by randomized controlled trials (RCTs) of organizational change (KQ 3) to improve screening, 

organizational change supported by monitoring and feedback systems (KQ 5) could have a 

positive effect on screening. Nonetheless, drawing conclusions on how to reduce overuse and 

misuse will always be difficult without adequate monitoring of these outcomes. 

A second important aspect of organization is external to the primary care practice. It involves 

coordination of various parts of the health care system involved in CRC screening. Because these 

parts of the health care system are often fragmented, barriers arise that patients must navigate to 

complete screening. These same barriers work against monitoring the progress of patients as they 

176 
move through the system or even providing assistance to those who cannot surmount the 

obstacles. Finally, these barriers create problems for providing consistent and timely information 

to patients and for establishing systems to reduce overuse and misuse. 

Limitations of this Review 

Limitations of the Evidence Base 

Reporting. Our ability to draw conclusions on the effectiveness of CRC screening 

interventions is limited by the relative paucity of detail on specific elements of the interventions. 

Studies inconsistently adhered to reporting standards such as STROBE218 and CONSORT,219 

making critical appraisal of internal validity and assessment of applicability challenging. In 

particular, many studies did not report on the intensity of the intervention (e.g., the number and 

length of sessions and the time period of interaction with clients), the existence of protocols 

governing the intensity of intervention, or fidelity to such protocols. In addition, a number of 

studies used multiple components of interventions (e.g., reminders paired with one-on-one 

interactions) to increase CRC screening but only provided overall findings. Reporting findings in 

this way made discerning the incremental impact of each component difficult if not impossible to 

assess. CRC screening interventions represent an opportunity to translate effective interventions 

into a variety of clinical settings; the absence of information on fidelity limits their translation. 

Heterogeneity of the interventions and the intervention sites. Categorizing the 

interventions was complicated by the heterogeneity of approaches, even for interventions that we 

eventually placed in the same category. The problem of classification was also complicated by 

the diversity of the sites in which the interventions occurred. In a sense, for example, an 

intervention that would be considered a “reminder” in one location might be considered a small 

media intervention in a different location. 

Choice of appropriate comparators. The evidence base for interventions is marked by 

heterogeneity in comparators in addition to appreciable diversity in the CRC screening measure 

itself. Although appropriate comparators can and should differ by the specific outcomes being 

addressed, studies often did not justify the choice of comparator(s), either on its own merits or in 

relation to usual care. In most cases for studies included in KQ 3, investigators did not define 

“usual care”; this ambiguity hampers accurate interpretation of comparisons. For that reason, our 

conclusions regarding the effectiveness of CRC screening interventions are necessarily limited. 

We also note that a potential Hawthorne effect may exist for studies comparing CRC 

screening interventions with usual care as opposed to a “sham” control. In cases involving 

comparisons of different types of CRC screening interventions, all interventions may receive a 

Hawthorne boost. This possibility makes distinguishing the different effects of the various 

interventions difficult. 

Choice of appropriate outcomes. As with the comparators, we encountered problems 

assessing the studies for each key question because of the way researchers defined and 

operationalized CRC screening. For studies that examined factors related to screening (KQ 2), 

many investigators used different definitions for CRC screening, partly because of a national 

trend toward colonoscopy and away from FOBT and sigmoidoscopy during the period of this 

review. Some teams considered subjects screened if they had ever received one type of test; 

others were more precise in including both the test and the recommended timeframe in their 

calculation of up-to-date screenings; while others included any CRC test code in their analysis, 

177 
regardless of whether the test was provided as a screening or diagnostic procedure, thereby 

increasing the challenge in determining which factors were truly related to screening.. 

Even with these variations in the guidelines, how researchers operationalized the outcome of 

being up to date was inconsistent in this body of literature. Thus, assessing both the effectiveness 

of interventions (KQ 3) and the factors associated with screening (KQ 2) was overly challenging, 

particularly with regard to assessing the appropriateness of screening. 

KQ 4 also presented challenges in assessing capacity outcomes and systematically applying 

these to a wide range of modeling assumptions; these problems in turn made synthesizing the 

findings difficult. Studies pertaining to this topic were also inconsistent in how they considered 

the difference between screening and diagnostic colonoscopy. Some modeling studies were 

unclear about whether they included surveillance colonoscopy in their calculation that would 

result from increased number of screening tests. 

Across KQs 2, 3, and 4, we observed a heavy reliance on self-reported data that are not 

verified through other sources; this problem, too, complicates drawing reliable conclusions. 

Questions to assess self-report were not standardized, despite an NCI-led effort to develop 

standardized survey questions that have been subsequently evaluated in validation studies.211-214 

Study design and sample size. Most KQ 2 studies were cross-sectional rather than cohort 

designs; thus, we could not easily examine time relationships. For this reason, there were no 

studies that examined factors associated with appropriate annual or serial use of FOBT, for 

example, and only focused on one-time or current use. Many studies did not report a priori 

hypotheses about their primary outcomes. Limited sample sizes resulted in studies that were not 

powered to find differences between experimental and control or comparison groups when such 

differences might in fact have existed. 

In addition, the time periods in which investigators followed patients during intervention 

implementation for KQ 3 studies or measured capacity for KQ 4 studies varied considerably. 

Sometimes time frames were not specified at all. Again, these deficiencies hampered our ability 

to draw any conclusions across the studies. For KQ 3 studies in particular, time periods for 

following patients ranged from 3 to 24 months. Establishing a more common time for followup 

would improve the overall strength of evidence for these studies. 

Appropriate adjustment for confounding. The evidence base is also limited by variations 

in the specific confounders and effect modifiers that investigators included or controlled for in 

their analyses. This issue arose particularly for examining factors influencing screening (KQ 2) 

and for quantifying capacity and projected demand (KQ 4). Omitting important confounders and 

effect modifiers (e.g., patient factors known to impact test use, temporal factors such as large 

macro-media campaigns such as when Katie Couric had a colonoscopy on national television), 

especially cointerventions in comparison arms, limits the interpretability and utility of the 

evidence from such investigations. Furthermore, using the studies that did account for 

confounders and effect modifiers is hampered by the lack of consistent definition and inclusion 

of key variables. 

These deficiencies together appreciably limit the consistency and validity of the evidence. As 

a result, we found several bodies of evidence for important outcomes that we could grade only as 

low strength of evidence. 

Limitations of the Review 

We limited our search to articles published in English, primarily because the focus of this 

review was the United States. Issues of the use and quality of CRC screening likely vary by 

178 
country. Our review does not address the nature, outcomes, or interventions developed in other 

countries. We excluded RCTs with samples sizes less than 30 and observational studies with 

samples sizes less than 100. We also limited the studies to those reporting on data collected from 

January 1998. 

For time and resource reasons, we did not conduct dual independent, blinded review of 

articles for abstraction of information into evidence tables. Instead, one reviewer performed the 

initial review, and a second reviewer examined that input and recommended changes or 

corrections when needed. These two reviewers reconciled any differences by consensus 

discussion. We did apply dual independent review for assessing the quality of individual articles 

and grading the strength of evidence, and often involved a third team member to resolve 

disagreements about these issues. These are, generally speaking, standard approaches for the 

RTI-UNC EPC. 

The paucity of similar articles—taking populations, patient characteristics, settings, and the 

heterogeneity and complexity of the interventions and the outcomes measured—precluded any 

efforts to pool findings statistically. 

Future Research Directions 

The last key question (KQ 6) is to assess “What research is needed to make the most progress 

and have the greatest public health impact in promoting the appropriate use of colorectal cancer 

screening?” We found numerous gaps in the available research that could be addressed to help us 

better understand and influence CRC screening rates. We summarize our suggestions for future 

research in Table 56. 

Table 56. Suggested research agenda to improve the appropriate use and quality of CRC screening (priority 

areas in bold font) 

Key Question Topic Research Agenda 

1: Trends in Underuse 

appropriate use and 

quality 

Overuse 

Misuse 

2. Factors influencing 

the use and quality of 

appropriate CRC 

screening 

Patient 

characteristics 

Physician 

characteristics 

Systems 

Coordinate reporting from BRFSS and NHIS systems with Medicare, 

HEDIS, and other administrative data to provide a single national 

source for use and trends. Standardize questions and measures. 

Develop new sources of use data from medical practices. 

Develop monitoring systems for screening of patients unlikely to 

benefit because of age or comorbidities. Develop monitoring 

systems for polypectomy rates for diminutive polyps. Develop 

monitoring systems for surveillance after polypectomy. 

Develop monitoring systems for use of in-office FOBT testing; 

nonreturn of FOBT cards; nonfollowup of positive FOBT tests; 

adverse events rates from colonoscopy; rates of inadequate 

colonoscopic insertion and too-rapid withdrawal. 

Examine patient factors associated with better understanding of 

screening, and with having a regular source of care after having health 

insurance. Examine patient preferences for receiving information about 

CRC screening, and preferences among CRC screening tests. 

Examine physician characteristics associated with underuse of 

discussion and screening; and with overuse and misuse of screening. 

Examine the interaction of various systems and different patient 

populations with CRC screening. Are different systems associated with 

underuse, overuse, or misuse in different patient populations? Consider 

systems within primary care practices and systems that include primary 

care and colonoscopy testing facilities. 

179 
3. Intervention Underuse 

strategies to improve 

appropriate screening 

Overuse and 

misuse 

Develop and test promising interventions that need more research, 

especially integrated with other practice systems and especially in 

combinations, paying special attention to what strategies work 

best (and are most cost-effective) in various patient populations. 

Should use outcomes of CRC screening and discussions. 

Develop and test strategies, including monitoring systems, to 

reduce overuse and misuse. 

4. Current capacity, Current capacity Studies examining national and regional current capacity for FS and for 

projected demand, and colonoscopy. 

projected capacity to 

meet screening and Projected Studies examining projected capacity under various realistic screening 

surveillance needs capacity and training scenarios, perhaps including trained nurse endoscopists 

(and projections in the context of future physicians trained?). 

5. Effective 

approaches for 

monitoring appropriate 

use and quality 

Underuse 

Overuse 

Misuse 

As in KQ 1, develop and evaluate national or regional monitoring 

systems that provide routine data on use and quality in a useful 

and timely form, with feedback mechanisms to encourage 

improvement. 

BRFSS, Behavioral Risk Factor Surveillance Survey; CRC, colorectal cancer; FOBT. fecal occult blood test; HEDIS, Healthcare Effectiveness 

Data and Information Set; KQ, key question; NHIS, National Health Interview Survey, 

The priority for research should be RCTs of interventions to implement appropriate CRC 

screening (i.e., minimizing underuse, overuse, and/or misuse) and monitoring linked to 

improvement initiatives. In our review, we became aware of multiple studies of the operating 

characteristics of potential new CRC tests. Although improving screening tests is a reasonable 

research agenda (especially finding ways to reduce the need for the most invasive and expensive 

tests), screening could be balanced with research to find ways to implement screening programs 

that we already know are effective, working to minimize underuse, overuse, and misuse. To 

focus research primarily on developing newer screening tests without placing higher priority on 

implementation of the existing effective tests leaves the people of the United States with 

inadequate screening. At least as important as newer screening tests are improved access, 

improved communication, and improved organization. We present in this review results of the 

uses of CRC tests within the VA system, where access to health care and insurance coverage are 

addressed by being members of that system, demonstrating that in this system, the use of 

screening is greater than among the general public. We found that rates among respondents in a 

nationally representative sample of respondents in the 2005 National Health Interview Survey 

(NHIS) who reported being covered by military insurance were statistically significantly more 

likely to have been screened when compared to all other insured and uninsured respondents (31.6 

percent of those without insurance versus as high as 43.0 percent among insured respondents, 

compared to 67.9 percent among those with military insurance [P < 0.0001]).46 These findings 

indicate that when an organization is designed to provide screening to a population with 

consistent access to care, CRC screening rates can increase to levels seen for breast cancer 

screening with mammography. 

Not only must we understand the organizational and system features important to increasing 

screening, but research also needs to examine the effectiveness of strategies that target several of 

the screening steps discussed above. Only when all three steps are accomplished—access to 

primary care, discussion and recommendation, and providing assistance and reducing barriers to 

complete screening—would we expect screening rates to markedly improve. The interventions of 

client or patient reminders, one-on-one interactions, and interventions to eliminate structural 

barriers seem to hold promise in increasing screening. Their impact could be increased if 

combined with further interventions to assist patients in traversing the health care system to 

180 
complete screening. Patient reminders were an effective intervention in increasing cancer 

screening rates (including CRC screening) in a 2002 meta-analysis.220 In that meta-analysis, 

organizational change (such as the use of separate prevention clinics, use of a planned prevention 

visit, designation of nonphysician staff to do specific preventive care activities) was the most 

potent intervention in increasing preventive care.220 This study suggests that a combination of 

interventions may have the greatest impact on screening rates. 

Interventions should be tested that work to optimize CRC screening together with other 

appropriate screening programs. Some of these interventions could target clinicians. We included 

two studies that examined the impact of provider-level interventions (for screening186 or 

surveillance colonoscopy188). Considering the central place that clinicians and their staff have in 

the screening steps, this is a potentially promising target to improve screening rates, particularly 

if it increases discussions between patients and providers. 

In addition, cost-effectiveness studies of successful interventions to improve screening and 

monitoring, and then pragmatic trials that are focused on implementation of successful strategies 

within actual primary care practice are urgently needed. Different intensities of interventions, 

and even wholly different interventions, will likely be needed for different populations. 

Interventions should be targeted at the specific steps that are problems for specific populations 

(e.g., those who speak other languages than English at home could likely benefit from more basic 

interventions to increase awareness and discussions, whereas those who are already obtaining 

screening on an irregular basis may benefit most from patient reminders). 

Further, we also need continued research into measuring current volume and projected 

demand for screening strategies. Finally, we found little evidence that adequate monitoring 

systems that assess the full spectrum of appropriate CRC screening (including overuse, underuse, 

and misuse) are in widespread use, and are being used to improve screening. Such monitoring 

systems are critically important for continued improvement of CRC screening. There is clearly a 

large and important research agenda for the future. 

This research should target more than overcoming the underuse of CRC screening, as 

important as that is. We found little research interest in reducing underuse of patient-physician 

discussions about CRC screening, or in reducing overuse and misuse of CRC screening. This 

research should be a priority in that the issues of high overuse and high misuse are prevalent in 

today’s US health care. 

Conclusions 

Our review suggests that the United States is yet some distance from fully realizing the 

promise of appropriate and high-quality CRC screening. Problems of underuse, overuse, and 

misuse are not being adequately addressed at present. By focusing our research effort on the 

issues that matter most—access to screening, communication between patient and medical staff, 

the organization of care—and by further researching how to implement effective and costeffective strategies into actual primary care practice, we will have the greatest opportunity to 

reduce the burden of suffering of CRC for the people of the United States. 

181 

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List of Abbreviations 

ACS American Cancer Society 

AHRQ Agency for Healthcare Research and Quality 

AOR adjusted odds ratio 

BRFSS Behavioral Risk Factor Surveillance Survey 

CAD computer-aided detection 

CAHPS Consumer Assessment of Healthcare Providers and Systems 

CCME Carolina Center for Medical Excellence 

CDC Centers for Disease Control and Prevention 

CHIS California Health Interview Survey 

CI confidence interval 

CONSORT Consolidated Standards of Reporting Trials 

CORI Clinical Outcomes Research Initiative 

CPT current procedural terminology 

CRC colorectal cancer 

CT computed tomography 

CTC computed tomographic colonography 

CTS Community Tracking Study 

DCBE double contrast barium enema 

DERS Direct Endoscopic Referral System 

DNA deoxyribonucleic acid 

DRE digital rectal examination 

FAP familial adenomatous polyposis 

FIT fecal immunochemical test 

FSS fee-for-service 

FFS + SUPP fee-for-service Medicare + supplemental insurance 

FIT fecal immunochemical test 

FOBT fecal occult blood test 

FS flexible sigmoidoscopy 

gFOBT guaiac-based fecal occult blood test 

G group 

GI gastrointestinal 

GI gastroenterologist 

HEDIS Healthcare Effectiveness Data and Information Set 

HINTS Health Information National Trends Survey 

HMO health maintenance organization 

HNPCC hereditary nonpolylposis colorectal cancer 

ICD International Classification of Diseases 

iFOBT immunochemical fecal occult blood test 

KQ key question 

LHA lay health advisors 

MCA managed care activity 

MCBS Medicare Current Beneficiary Survey 

MEPS Medical Expenditure Panel Survey 

MeSH Medical Subject Heading 

191 
MMC Medicare managed care 

MMSA metropolitan or micropolitan statistical areas 

MR magnetic resonance 

MRI magnetic resonance imaging 

MSTF Multi-Society Task Force 

MSTF Multi-Society Task Force 

NCI National Cancer Institute 

NCQA National Committee on Quality Assurance 

NHIS National Health Interview Survey 

NIH National Institutes of Health 

N number 

NR not reported 

OMAR Office of Medical Applications of Research 

OR odds ratio 

PCP primary care physician 

PET positron emission tomography 

PHE periodic health examination 

PSA prostate-specific antigen 

PSAs	 public service announcements 

RCTs randomized controlled trials 

RDD random digital dialing 

RR relative risk 

RTC Randomized Control Trial 

RTI-UNC EPC RTI International–University of North Carolina Evidence-based Practice 

Center 

SES socioeconomic status 

SI standard intervention 

STROBE STrengthening the Reporting of OBservational studies in Epidemiology 

TEP Technical Expert Panel 

TFCPS Task Force on Community Preventive Services 

TI tailored intervention 

TIP tailored intervention plus reminder phone call 

US United States 

USPSTF US Preventive Services Task Force 

VA Veterans Administration 

192 
Glossary 

Ability to meet projected demand: the ability of current capacity (or projected capacity if known) 

to meet the projected demand under various demand scenarios, such as screening the 

entire eligible US population with a specific test. 

Acceptability—Willingness of persons and organizations to participate in the monitoring system 

Appropriate use (of CRC screening)— minimizing overuse and misuse as well as underuse 

Compliance—Degree to which a system complies with all relevant legislation, regulations, and 

policies 

Consistency—degree to which reported effect sizes from included studies appear to go in the 

same direction 

Cost—Indirect and direct costs 

Current capacity (or current potential volume)—the sum of current volume and additional 

available capacity, where: 

•	 Current volume is the estimate of the current number of FS or colonoscopy 

procedures conducted in the present year; and 

•	 Additional available capacity is the number of additional FS or colonoscopy 

procedures that could be conducted in the current year. 

Data quality—Completeness and validity of the data in the system 

Directness—the extent to which evidence links the compared interventions directly to health 

outcomes 

Discussions-- discussions of CRC screening between physicians and patients includes a 

conversation covering such areas as pros and cons of screening options and eliciting 

patient preferences and is meant as more than simply the physician recommending testing 

Flexibility—Ability of the system to accommodate changes in operating conditions or 

information needs 

Followup—clinical procedures and tracking of patients who have received an abnormal 

colorectal cancer screening result 

Lay health advisors—people with no clinical training who serve as educators of peers for various 

health issues 

Monitoring—tracking and data collection of the use and/or quality of colorectal cancer screening 

(such as with a national surveillance data system) 

193 
Overall Strength of Evidence (SOE)—reflects a global assessment that takes the required 

domains (i.e., risk of bias, consistency, prevision, directness) directly into account. Levels 

of SOE include: 

•	 High—High confidence that the evidence reflects the true effect. Further research is 

very unlikely to change our confidence in the estimate of effect. 

•	 Moderate—Moderate confidence that the evidence reflects the true effect. Further 

research may change our confidence in the estimate of effect and may change the 

estimate. 

•	 Low—Low confidence that the evidence reflects the true effect. Further research is 

likely to change our confidence in the estimate of effect and is likely to change the 

estimate. 

•	 Insufficient—Evidence either is unavailable or does not permit estimation of an 

effect. 

Patient level intervention terms: 

•	 Small media—educational materials provided as videos and/or printed materials such 

as letters, brochures, and newsletters to inform people about specific diseases or 

health issues 

•	 Decision aids—mechanisms or interventions that have been developed to improve 

communication between health professionals and patients; their goal is to help 

involve patients in making decisions regarding their health care 

•	 Group education—workshop or presentation conducted within a specified group 

setting to deliver educational information or motivation to encourage screening 

•	 One-on-one interactions—studies in which a provider (e.g., physician, nurse, health 

educator) works individually with patients to educate them about CRC screening 

and/or aid them in making decisions about which tests to complete and when to 

receive screening. These interventions tend to include some concentrated time with a 

patient to answer questions, address concerns, and help facilitate completion of 

screening tests. 

•	 Eliminating structural barriers—interventions that seek to increase screening by 

removing structural barriers (e.g., offer more screening times or locations, provide 

transportation to a service, etc.) 

•	 Patient reminders—provided to patients (e.g., via mailed letters or phone calls) who 

are due for a rescreening or who have never been screened to prompt people about 

their need for annual screening (or for screening related to whatever period 

recommended for the patient) 

Precision—degree of certainty surrounding an effect estimate with respect to a given outcome 

(i.e., for each outcome separately) 

Projected capacity—future capacity to conduct FS or colonoscopy under various scenarios such 

as changes in workforce or changes in the number of facilities that provide procedures. 

194 
Quality (of CRC tests) — “underuse,” “overuse,” and “misuse” of screening tests rather than test 

performance 

Quality rating—internal validity or risk of bias (of studies) 

Risk of bias—degree to which the included studies for any given outcome or comparison have a 

high likelihood of adequate protection against bias (i.e., good internal validity) 

Simplicity—Structure and ease of operation 

Stability—Reliability (ability to collect, manage and provide data properly without failure) and 

availability (ability to be operational when it is needed) of the monitoring system 

Surveillance—in terms of data collection, we opted to replace the term ‘surveillance’ with regard 

to data collection with the term ‘monitoring’. In terms of surveillance of colorectal cancer 

screening results, because of initial abnormal results, we have used the term ‘followup’ 

instead. 

Surveillance colonoscopy—colonoscopy for patients who have had a previous colonic polyp 

(and, usually, polypectomy) 

Timeliness—Interval between occurrence of an event and reporting of the event. 

195 
196 
Appendix A 

197 
Appendix A. Colorectal Cancer Search Strategy 

#1 Search "Colorectal Neoplasms" [MeSH] OR "Mass Screening"[Majr] 154648 

#2 Search (("Colonoscopy"[Mesh] OR "Colonography, Computed Tomographic"[Mesh])) OR 26681 

"Sigmoidoscopes"[Mesh] OR "stool test" OR "fecal immunochemical testing" OR (FIT AND fecal) 

OR fobt OR fobt OR occult blood OR "DNA Stool" 

#3 Search "Polyps"[Mesh] AND "Biopsy"[Mesh] 967 

#4 Search #2 OR #3 27451 

#5 Search #1 AND #4 9033 

#6 Search #1 AND #4 Limits: Publication Date from 1998, Humans, English 4660 

#7 Search #1 AND #4 Limits: Publication Date from 1998, Humans, Review, English 705 

#8 Search ("Randomized Controlled Trials"[MeSH] OR "Randomized Controlled Trial"[Publication 336385 

Type]) OR "Single-Blind Method"[MeSH] OR "Double-Blind Method"[MeSH] OR "Random 

Allocation"[MeSH] 

#9 Search #6 AND #8 263 

#10 Search ("Case-Control Studies"[MeSH] OR "Cohort Studies"[MeSH] OR "Epidemiologic 1150609 

Studies"[MeSH] OR "Cross-Sectional Studies"[MeSH] OR "Organizational Case Studies"[MeSH] OR 

"Cross-Over Studies"[MeSH] OR "Follow-Up Studies"[MeSH] OR "Seroepidemiologic 

Studies"[MeSH] OR "Multicenter Studies"[MeSH] OR "Evaluation Studies"[MeSH]) OR 

Longitudinal Studies OR observational studies 

#11 Search #6 AND #10 1340 

#12 Search #7 OR #9 OR #11 2150 

#13 Search ("Colorectal Neoplasms/diagnosis"[Majr] OR "Colorectal Neoplasms/prevention and 29131 

control"[Majr]) 

#14 Search "Mass Screening"[Majr] 48233 

#15 Search #13 AND #14 2175 

#16 Search #15 NOT #12 1752 

#17 Search #15 NOT #12 Limits: Publication Date from 1998, Humans, English 1019 

#19 Search "United States"[Mesh] OR United States Limits: Publication Date from 1998, Humans, English 676580 

#20 Search #17 AND #19 Limits: Publication Date from 1998, Humans, English 399 

#21 Search #4 NOT #12 25301 

#22 Search #15 AND #21 1128 

#23 Search #15 AND #21 Limits: Publication Date from 1998, Humans, English 591 

#25 Search #19 AND #23 211 

Total PUBMED = 2265 

Cochrane Reviews = 7 = 6 New 

Cochrane Central Trials Registry = 138 = 38 New 

Total Unduplicated Database = 2309 

A-1 
 Update Search Strategy (September 21st 2009) 

#1 Search "Colorectal Neoplasms" [MeSH] OR "Mass Screening"[Majr] 158767 

#2 Search (("Colonoscopy"[Mesh] OR "Colonography, Computed Tomographic"[Mesh])) OR 27659 

"Sigmoidoscopes"[Mesh] OR "stool test" OR "fecal immunochemical testing" OR (FIT AND fecal) 

OR fobt OR fobt OR occult blood OR "DNA Stool" 

#3 Search "Polyps"[Mesh] AND "Biopsy"[Mesh] 987 

#4 Search #2 OR #3 28442 

#5 Search #1 AND #4 9346 

#6 Search #1 AND #4 Limits: Entrez Date from 2009, Humans, English 277 

#7 Search #1 AND #4 Limits: Entrez Date from 2009, Humans, Review, English 29 

#8 Search ("Randomized Controlled Trials"[MeSH] OR "Randomized Controlled Trial"[Publication 346335 

Type]) OR "Single-Blind Method"[MeSH] OR "Double-Blind Method"[MeSH] OR "Random 

Allocation"[MeSH] 

#9 Search #6 AND #8 21 

#10 Search ("Case-Control Studies"[MeSH] OR "Cohort Studies"[MeSH] OR "Epidemiologic 1192822 

Studies"[MeSH] OR "Cross-Sectional Studies"[MeSH] OR "Organizational Case Studies"[MeSH] OR 

"Cross-Over Studies"[MeSH] OR "Follow-Up Studies"[MeSH] OR "Seroepidemiologic 

Studies"[MeSH] OR "Multicenter Studies"[MeSH] OR "Evaluation Studies"[MeSH]) OR 

Longitudinal Studies OR observational studies 

#11 Search #6 AND #10 77 

#12 Search #7 OR #9 OR #11 118 

#13 Search ("Colorectal Neoplasms/diagnosis"[Majr] OR "Colorectal Neoplasms/prevention and 30104 

control"[Majr]) 

#14 Search "Mass Screening"[Majr] 49616 

#15 Search #13 AND #14 2272 

#16 Search #15 NOT #12 2250 

#17 Search #15 NOT #12 Limits: Entrez Date from 2009, Humans, English 67 

#18 Search "United States"[Mesh] OR United States 2377508 

#19 Search #17 AND #18 20 

#20 Search #4 NOT #12 28324 

#21 Search #15 AND #20 1592 

#22 Search #15 AND #20 Limits: Entrez Date from 2009, Humans, English 32 

#23 Search #18 AND #22 6 

Total PUBMED = 124 

Cochrane Reviews = 2 = 2 New 

Cochrane Central Trials Registry = 19 = New 14 

Total Unduplicated Database = 140 

A-2 
Appendix B 
GENERAL INFO PUBLICATION TYPE

Reviewer

initials

Ref

ID

Author,

Year

Not original

research

(e.g., review,

letter,

editorial)

Published as

abstract only (or

conference

proceeding, poster)

B-1
 
POPULATION OUTCOMES SETTING INTERVENTIONS

Wrong population‐‐High risk

population (diagnosis of other

illness, e.g., cancer, FAP, HNPCC,

UC, Crohns)‐‐Refer to study

population exclusion criteria box

from table

Wrong outcome‐‐refer

to study outcomes

exclusion box from

table Not U.S.

Wrong intervention‐‐

Not colonocsopy,

Sigmoidoscopy, CTC,

FIT, gFOBT, or DNA

stool

B-2
 
DESIGN OTHER BACKGROUND

Not about

screening

Exprimental

(RCT or

non‐

randomized

controlled

trial) N < 30

Observational

N < 100

Does not

address a

KQ

Other‐‐

specify

Exclude but

save for

background

Systematic

review

B-3
 
INCLUDE? KEY QUESTIONS (CHECK ALL THAT APPLY)

Article should

be included

If article is to

be included,

proceed; if not

STOP here

KQ1: What are

the recent

trends in the use

and quality of

CRC screening?

KQ2: What

factors

influence the

use of CRC

screening?

KQ3: Which strategies

are effective in

increasing the

appropriate use of CRC

screening and followup?

B-4
 
ALL THAT APPLY)

Comments, if

necessary

KQ4: What are the

current and projected

capacities to deliver CRC

screening and

surveillance at the

population level?

KQ5: What are the

effective approaches

for monitoring the use

and quality of CRC

screening?

B-5 

Appendix C 
Acronyms 

ACS American Cancer Society 

AHRQ Agency for Healthcare Research and Quality 

AOR adjusted odds ratio 

BRFSS Behavioral Risk Factor Surveillance Survey 

CAD computer-aided detection 

CAHPS Consumer Assessment of Healthcare Providers and Systems 

CCME Carolina Center for Medical Excellence 

CDC Centers for Disease Control and Prevention 

CHIS California Health Interview Survey 

CI confidence interval 

CONSORT Consolidated Standards of Reporting Trials 

CORI Clinical Outcomes Research Initiative 

CPT current procedural terminology 

CRC colorectal cancer 

CT computed tomography 

CTC computed tomographic colonography 

CTS Community Tracking Study 

DCBE double contrast barium enema 

DERS Direct Endoscopic Referral System 

DNA deoxyribonucleic acid 

DRE digital rectal examination 

FAP familial adenomatous polyposis 

FIT fecal immunochemical test 

FSS fee-for-service 

FFS + SUPP fee-for-service Medicare + supplemental insurance 

FIT fecal immunochemical test 

FOBT fecal occult blood test 

FS flexible sigmoidoscopy 

gFOBT guaiac-based fecal occult blood test 

G group 

GI gastrointestinal 

GI gastroenterologist 

HEDIS Healthcare Effectiveness Data and Information Set 

HINTS Health Information National Trends Survey 

HMO health maintenance organization 

HNPCC hereditary nonpolylposis colorectal cancer 

ICD International Classification of Diseases 

iFOBT immunochemical fecal occult blood test 

KQ key question 

LHA lay health advisors 

MCA managed care activity 

MCBS Medicare Current Beneficiary Survey 

MEPS Medical Expenditure Panel Survey 

MeSH Medical Subject Heading 

MMC Medicare managed care 

C-1
 
MMSA metropolitan or micropolitan statistical areas 

MR magnetic resonance 

MRI magnetic resonance imaging 

MSTF Multi-Society Task Force 

MSTF Multi-Society Task Force 

NCI National Cancer Institute 

NCQA National Committee on Quality Assurance 

NHIS National Health Interview Survey 

NIH National Institutes of Health 

N number 

NR not reported 

OMAR Office of Medical Applications of Research 

OR odds ratio 

PCP primary care physician 

PET positron emission tomography 

PHE periodic health examination 

PSA prostate-specific antigen 

PSAs	 public service announcements 

RCTs randomized controlled trials 

RDD random digital dialing 

RR relative risk 

RTC Randomized Control Trial 

RTI-UNC EPC RTI International–University of North Carolina Evidence-based Practice 

Center 

SES socioeconomic status 

SI standard intervention 

STROBE STrengthening the Reporting of OBservational studies in Epidemiology 

TEP Technical Expert Panel 

TFCPS Task Force on Community Preventive Services 

TI tailored intervention 

TIP tailored intervention plus reminder phone call 

US United States 

USPSTF US Preventive Services Task Force 

VA Veterans Administration 

C-2
 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening 

C-3
 

STUDY:	 Authors, ref ID: Afable-Munsuz A, Liang SY, Ponce NA, Walsh JME.1 

Year of publication: 2009 Dates of data collection: 2000-2005 Trial name: NA 

OBJECTIVE OR AIM: This study aimed to examine the relationships between acculturation and CRC screening 

Puerto-Rican and Cuban adults. 

DESIGN: Setting: US 

Study design: Cross-sectional retrospective study Duration (mean followup): NA Overall study size (N enrolled/N analyzed): 38,347 

Sample size: Mexican Puerto Rican Cuban Black 

Sample Size: 2,304 Sample Size: 503 Sample Size: 484 Sample size: 4,8

Describe intervention: RECRUITMENT: Population-based; this study used data from the 2000, 2003 and 2005 National Health Int

(population-based, clinic-based, volunteer, other) INCLUSION CRITERIA: Latinos 50 years and older, never diagnosed with CRC, and who were surveyed in the 20

National Health Interview Survey (NHIS) 

EXCLUSION CRITERIA:	 NA 

POPULATION CHARACTERISTICS: Mexican Puerto Rican	 

NR NR 

Mean age & range (years): Sex (% female): Race: Other: 

• Conducted interview in English 58% 60% •

only Born in the U.S. 56% 21% 

Mexican Puerto Rican 

Attrition/Drop-out (not available for endpoint measurement): Adherence: 

NA NA 

Contamination: Response Rates (e.g. for surveys): 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY:	 Authors, ref ID: Afable-Munsuz A, Liang SY, Ponce NA, Walsh JME.1 

Year of publication: 2009 Dates of data collection: 2000-2005 Trial name: NA 

C-4
 

STATISTICAL ANALYSES: Describe: 

•	 Authors examined bivariate and adjusted relationships between acculturatio

CRC screening outcomes. 

•	 Authors used chi-square tests to examine unadjusted associations between 

interview and the three outcomes. 

•	 Using logistic regression, models containing nativity, language of interview a

estimated to assess the independent contributions of each on the three outc

ASSESSMENT OF EXPOSURES AND POTENTIAL CONFOUNDERS: 

• Authors also analyze key covariates, including demographic variables (age, 

factors known as predisposing variables (income status, education), enablinhealth-care access (type of insurance and usual source of care) and health-of chronic diseases), which is a count variable ranging from 0 to 6, of whethehaving diabetes, hypertension, ulcer, arthritis, any cardiovascular disease an

OUTCOME ASSESSMENT: Outcome Measures: 

•	 Authors measured acculturation with US nativity and language of interview, 

different CRC screening outcomes: fecal occult blood test (FOBT) in the pasendoscopy and any up-to-date CRC screening. 

•	 Three CRC screening outcomes, available in the NHIS, were investigated: (

undergone FOBT in the past year, (2) whether individuals had received a sigyears or colonoscopy in the last 10 years and (3) whether individuals had rescreening (or met the criterion for no. 1 or 2). 

RESULTS: 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY:	 Authors, ref ID: Afable-Munsuz A, Liang SY, Ponce NA, Walsh JME.1 

Year of publication: 2009 Dates of data collection: 2000-2005 Trial name: NA 

C-5
 

KQ2 - What factors influence the use of Outcomes: colorectal cancer screening? FOBT in past year UTD endoscopy 

Mexico 10.9 23.6 

Puerto Rico 13.9 28.5 

Cuba 11.2 30.6 

Non-Hispanic Black 14.6 29.3 

Non-Hispanic White 16.8 38.3 

Screening outcomes by nativity and language of interview Results suggest “differential relationships between acculturation and CRC screening by nMexicans, the authors observed a positive relationship between US nativity and endoscopAmong Puerto Ricans, US nativity was associated with a lower likelihood of FOBT use. 

•	 Nativity and language of interview were not significant correlates of any up-t

among Puerto Ricans and Cubans. Mexicans born in the U.S. had higher oscreening. (OR=1.4, 95% CI 1.0-1.9) 

•	 Higher family income (95% CI: 200-399% FPL (1.3, 6.0) and a greater numb

(95% CI: 1.3, 2.0) were significantly associated with a higher likelihood of anscreening among Cubans. 

•	 For FOBT, the study’s acculturation measures were only significant among P

•	 It is notable that higher educational level (some college 95% CI: 1.6, 5,5) an

chronic conditions (95% CI: 1.2, 1.6) were also significant and positively relaFOBT in the past year among Puerto Ricans. 

•	 Among Mexicans, having a usual source of care (95% CI: 1.4, 3.5) and a gre

conditions (95% CI: 1.2, 1.4) were significant and positive correlates of FOB

•	 Among Cubans, male gender (95% CI: 1.0, 2.5) was the only significant, pos

outcome. 

•	 English language was positively associated with FOBT in past year (AOR, 2•	 US born among Mexicans was positively associated with endoscopy (AOR, 

negatively associated with FOBT among Puerto Ricans (AOR, 0.3; 95% CI, 

KQ3 - Which strategies are effective in Outcomes: 

increasing the appropriate use of NA colorectal cancer screening and
 followup?
 KQ4 - What are the current and NA projected capacities to deliver colorectal cancer screening and surveillance at the population level? 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY:	 Authors, ref ID: Afable-Munsuz A, Liang SY, Ponce NA, Walsh JME.1 

Year of publication: 2009 Dates of data collection: 2000-2005 Trial name: NA 

C-6
 

KQ5 - What are the effective approaches NA for monitoring the use and quality of colorectal cancer screening? QUALITY RATING: Good 

Quality Assessment-Internal Validity for Observational Studies 

Yes No Other (CD, NR, NA) 

Were the groups similar at baseline regarding the most NR important prognostic indicators? Were the drop-out or response rates acceptable (≤ 20%)? [If NA 

between 20% and 60%, check other and explain.] Were the differential drop-out or response rates acceptable (≤ NA 

15%)? Were intervention/exposure measures valid, reliable, and NA equally applied? Were the outcome assessors blinded to the intervention or NA exposure status of subjects? Were outcome measures valid, reliable, and equally applied? X Does the analysis control for baseline differences? X Were important potential confounding and modifying X variables taken into account in the design and analysis (e.g., through matching, stratification, or statistical adjustment)? Were the statistical methods used to assess the abstracted X outcomes appropriate? Quality Rating (Good, Fair, or Poor): Good 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY:	 Authors, ref ID: Ananthakrishnan, A.N., et al.2 

Year of publication: 2007 Dates of data collection: 2002-2003 Trial name: NA 

OBJECTIVE OR AIM: To identify sex, age, socioeconomic, and racial/ethnic disparities in colon cancer screenin

beneficiaries in Illinois, New York, and Florida since institution of the expanded coverage. 

DESIGN: Setting: Medicare claims data 

Study design: Cross-sectional retrospective Duration (mean followup): No follow-up Overall study size (N enrolled/N analyzed): 596,470 Florida Illinois New York 

Sample size: Sample size: 228,853 Sample size: 161,867 Sample si

No intervention, Medicare claims No intervention, Medicare claims No interve

Describe intervention: data data data RECRUITMENT: Claims-based; Medicare physician/supplier file, which is derived from Medicare Part B cla(population-based, clinic-based, and the denominator file; a one-fifth sample of eligible subjects enrolled in both Parts A anvolunteer, other) their care through the Medicare fee-for-service system in each of the 3 states of New York

during 2002 and 2003, was identified. 

C-7INCLUSION CRITERIA:	 Age 65+ 

EXCLUSION CRITERIA: Individuals with a personal history of c

V10.05 and V10.06), or inflammatory byears or with missing data on race/eth

olon polyps (ICD-9 codes V12.72, 211.3, and 211.4

owel disease (ICD-9 555.x, 556.x, 558.

nicity or sex 

2, and 558.

POPULATION CHARACTERISTICS: Florida Illinois New Yor

Age: 27.4% 65-69, 27.8% 70-74, Age: 28.1% 65-69, 27.4% 70-74, Age: 26.4

Mean age & range (years): Sex (% female): Race: 

23.4% 75-79, 21.5% 80+ Sex: 58.2% female Race: 90.8% White, 5.4% Black, 

22.9% 75-79, 21.7% 80+ Sex: 60.8% female Race: 90% White, 7.9% Black, .6% 

23.3% 75Sex: 61.2Race: 87

.5% Pacific Islander, .4% Asian, Pacific Islander, .6% Asian, .8% 1.1% Pac

Other: 2.9% Hispanic, .1% Native American Hispanic, .1% Native American 2.2% Hisp

Attrition/Drop-out (not available for endpoint measurement): Adherence: 

NA 

Contamination: Response Rates (e.g. for surveys): 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY: Authors, ref ID: Ananthakrishnan, A.N., et al.2 

Year of publication: 2007 Dates of data collection: 2002-2003 Trial name: NA 

STATISTICAL ANALYSES: Describe: 

Authors calculated the percentages of patients who had undergone any colorectal cancer 

for each individual test authors analyzed the screening practices by age group, sex, race/achievement, per capita income level, and state of residence using univariate analysis. All variables showing a significant association (P<.05) with the outcome were included in 

to arrive at adjusted estimates. In addition, authors analyzed interactions between the demographic variables (age, sex, asocioeconomic markers (educational achievement and per capita income level) and betwedemographic variables. Interactions that were statistically significant (P<.05) were included in the final model. 

ASSESSMENT OF EXPOSURES AND NR POTENTIAL CONFOUNDERS: 

C-8
 

OUTCOME ASSESSMENT: Outcome Measures: 

Screening procedures were identified using the following Health Care Financing AdministCoding System and Current Procedural Terminology codes: colonoscopy (44388, 44389, 45378, 45380, 45383, 45384, 45385, G0105, and G0121), sigmoidoscopy (45300, 4530545320, 45330, 45331, 45333, 45338, 45339, and G0104), DCBE (74270, 74280, G0106, FOBT (G0107 and G0328). Authors considered the procedures to be screening tests if they were coded using the releFinancing Administration Common Procedure Coding System codes or using the appropr

screening (V76.51 and V76.51). 

RESULTS: 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY:	 Authors, ref ID: Ananthakrishnan, A.N., et al.2 

Year of publication: 2007 Dates of data collection: 2002-2003 Trial name: NA 

KQ2 - What factors influence the use of colorectal cancer screening? 

Outcomes: Overall screening for colon cancer varied by race/ethnicity, income level, and educational sex. An equal proportion (18.3%) of men and women had undergone a screening colon te

Hispanics (8.1%) had lower rates of colon cancer screening compared with whites (19.3%codes with a higher per capita income were more likely to undergo a colon screening test ZIP codes with a lower per capita income (21.0% and 14.6% in the highest and lowest terPatients 80+ years were less likely to have received any CRC test than other age groups, range, 0.84-0.90). There was a significant interaction between age group and sex (P<.001) and between incfor all screening tests and in an analysis restricted to screening colonoscopy alone. There interaction between race/ethnicity and both sex and income level for screening colonosco

C-9
 

KQ3 - Which strategies are effective in Outcomes: increasing the appropriate use of NR colorectal cancer screening and
 followup?
 KQ4 - What are the current and Outcomes: projected capacities to deliver NR colorectal cancer screening and
 surveillance at the population level? KQ5 - What are the effective approaches Outcomes: for monitoring the use and quality of NR colorectal cancer screening? QUALITY RATING: Fair 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

Quality Assessment-Internal Validity for Observational Studies 

Yes No Oth

Were the groups similar at baseline regarding the most important prognostic indicators? X Were the drop-out or response rates acceptable (≤ 20%)? [If between 20% and 60%, check other and NA 

explain.] Were the differential drop-out or response rates acceptable (≤ 15%)? NA 

Were intervention/exposure measures valid, reliable, and equally applied? NA Were the outcome assessors blinded to the intervention or exposure status of subjects? NA 

Were outcome measures valid, reliable, and equally applied? X Does the analysis control for baseline differences? X Were important potential confounding and modifying variables taken into account in the design and X 

analysis (e.g., through matching, stratification, or statistical adjustment)? Were the statistical methods used to assess the abstracted outcomes appropriate? X 

Quality Rating (Good, Fair, or Poor): Fair 

C-10
 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

C-11
 

STUDY: Colorectal cancer prevention: Authors, ref ID: Ata et al.3 Adherence patterns and correlates of tests Year of publication: 2006 done for screening purposes within United Dates of data collection: data from NHIS 2000 sample States populations Trial name: data from NHIS used for this study OBJECTIVE OR AIM: In this study, they estimate the use of the tests recommended for CRC preventive screeni

variable accounting for adherence to: (1) any combination of recommended tests (2) withi

guidelines and (3) done specifically for screening purposes. They also examine the effect documented and potential predictors, on the test usage based upon our outcome variableinfluence of predictor variables between and within racial/ethnic groups with a goal of guidimprovement strategies. 

DESIGN: Setting: United States, NHIS 2000 Study design: cross-sectional, modeling (kq2) 

Duration (mean follow-up): no follow-up data reported Overall study size (N enrolled/N analyzed): 

sample of 12,498 people, 

Sample size: representing an age-appropriate 

population of 72.3 million 

Describe intervention: NA RECRUITMENT: Population based (population-based, clinic-based, volunteer, other) INCLUSION CRITERIA: The study included only those people who were 50 years or more in age. EXCLUSION CRITERIA:	 The study excluded people who reported ever having cancer of the colon or rectum. 

POPULATION CHARACTERISTICS: 

NR 

Mean age & range (years): 

Sex (% female): Race: Other: Attrition/Drop-out (not available for NA endpoint measurement): Adherence:
 Contamination: Response Rates (e.g. for surveys): Annual response rate of the NHIS is greater than 90% of the eligible 

households in the sample 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY: Colorectal cancer prevention: Authors, ref ID: Ata et al.3 Adherence patterns and correlates of tests Year of publication: 2006 done for screening purposes within United Dates of data collection: data from NHIS 2000 sample States populations Trial name: data from NHIS used for this study STATISTICAL ANALYSES: Descriptive statistics and a multiple logistic regression model with all the independent vari

the odds of compliance for each of the predictor variables while controlling for the other va

ASSESSMENT OF EXPOSURES AND POTENTIAL CONFOUNDERS: 

(a) socio-demographics: age, gender, marital status, education, 

annual family income, region, and size of metropolitan statistical area (MSA) of residence(b) healthcare access and utilization: having health insurance, a usual source of healthcare, and time since last visit to a doctor; (c) health risk and health status: family history of any cancer, a personal history of other cancers and perceived health status; (d) behavioral/lifestyle: smoking, body mass index (BMI), and exercise.
 

OUTCOME ASSESSMENT: (1) any combination of recommended tests (2) done within their respective time guidelines

screening purposes. 

Results KQ2 - What factors influence the use of colorectal cancer screening? 

Hispanics less likely to be adherent for timescreening in unadjusted and adjusteTable. Comparison of multivariate adjusted OR’s and 95% CI for ‘time only’ and ‘time-s(NHIS 2000) 

Variable Adherent for time and purpose (n=9575

(%) (CI for %) OR 

Overall population 25.8 (24.9, 26.7) - Race  Non-Hispanic White  Hispanics  Non-Hispanic Black 

27.3 15.8 22.7 

(26.3, 28.3) 

(13.5, 18.5) 

(20.1, 25.6) 

1.00 0.73 

1.13 

Age (y) 50-54 55-59 60-64 65-69 70-74 >=75 

19.7 

25.6 26.7 30.9 30.5 26.5 

(17.9, 21.7) 

(23.3, 27.9) (24.4, 29.1) (28.5, 33.5) (27.9, 33.3) 

(24.4, 28.6) 

1.00 1.51 1.70 2.14 2.20 2.08 

Gender  Female 23.9 (22.8, 25.1) 1.00 

C-12
 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY: Colorectal cancer prevention: Adherence patterns and correlates of tests done for screening purposes within United States populations 

Authors, ref ID: Ata et al.3 

Year of publication: 2006 Dates of data collection: data from NHIS 2000 sample Trial name: data from NHIS used for this study

 Male 28.0 (26.6, 29.5) 1.16 Marital status  Married, living with spouse  Rest of population 

28.7 

20.9 

(27.4, 30.0) 

(19.8, 22.1) 

1.26 

1.00 

A usual place of health care No Yes 

9.5 

27.1 

(7.5, 11.9) 

(26.1, 28.1) 

1.00 

1.61 

Time since last doctor visit  <= 6 mos  > 6 mos – 1 yr  > 1-2 yrs  > 2 yrs 

28.9 

22.9 

11.2 

3.7 

(27.8, 30.0) 

(20.3, 25.8) 

(8.4, 14.7) 

(2.3, 5.9) 

7.59 

5.86 

2.76 

1.00 

Family h/o ca No Yes 

23.8 

30.6 

(22.4, 25.3) 

(29.3, 32.0) 

1.00 1.27 

h/o other cancer No Yes 

24.9 

32.3 

(24.0, 25.9) 

(29.6, 35.0) 

1.00 1.08 

Perceived health status  Excellent  Very good Good Fair Poor 

30.1 

27.7 

24.6 

21.1 

20.1 

(28.1, 32.1) 

(26.1, 29.4) 

(23.0, 26.3) 

(19.1, 23.4) 

(17.2, 23.3) 

1.00 0.90 0.83 0.77 0.73 

Smoking status Non-smoker Smoker Quitter 

25.1 

18.2 

30.9 

(23.8, 26.5) 

(16.3, 20.3) 

(29.3, 32.6) 

1.00 0.89 1.11 

C-13
 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY: Colorectal cancer prevention: Adherence patterns and correlates of tests done for screening purposes within United States populations 

Authors, ref ID: Ata et al.3 

Year of publication: 2006 Dates of data collection: data from NHIS 2000 sample Trial name: data from NHIS used for this study 

BMI  Underweight Normal Overweight Obese 

17.6 

25.5 

27.6 

26.6 

(13.3, 22.8) 

(24.0, 27.0) 

(26.1, 29.2) 

(24.7, 28.5) 

0.81 

1.00 

1.07 

1.14 

KQ3 - Which strategies are effective in increasing the appropriate use of colorectal cancer screening and followup? 

NA 

KQ4 - What are the current and projected capacities to deliver colorectal cancer screening and surveillance at the population level? 

NA 

KQ5 - What are the effective approaches for monitoring the use and quality of colorectal cancer screening? 

NA 

QUALITY RATING: Good

C-14
 

Quality Assessment-Internal Validity for Observational Studies 

Yes No Othe

Were the groups similar at baseline regarding the most important prognostic indicators? NA 

Were the drop-out or response rates acceptable (≤ 20%)? [If between 20% and 60%, check other and X As m

explain.] to NWere the differential drop-out or response rates acceptable (≤ 15%)? NA 

Were intervention/exposure measures valid, reliable, and equally applied? X Were the outcome assessors blinded to the intervention or exposure status of subjects? NA 

Were outcome measures valid, reliable, and equally applied? X Self-

overHowabouthis l

Does the analysis control for baseline differences? X Were important potential confounding and modifying variables taken into account in the design and X analysis (e.g., through matching, stratification, or statistical adjustment)? Were the statistical methods used to assess the abstracted outcomes appropriate? X 

Quality Rating (Good, Fair, or Poor): Good 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

C-15
 

STUDY:	 Authors, ref ID: Atlas4 

Year of publication: 2009 Dates of data collection: 2003 to 2005 Trial name: NR 

OBJECTIVE OR AIM: To determine whether patient–physician connectedness affects measures of clinical perfo

DESIGN: Setting: Academic network of 4 community health centers and 9 hospital-affiliated primar

Massachusetts General Hospital Primary Care Network Study design: Population-based retrospective cohort study Duration (mean followup): Overall study size (N enrolled/N analyzed): 155,590 

Sample size (all patients): Sample size (colorectal patients only): 

Physician connected 

92,315 31,215 

Practice connected 

53,669 

6,453 

Describe intervention: NA RECRUITMENT: Clinic based (population-based, clinic-based, volunteer, other) INCLUSION CRITERIA: All patients with a visit to 1 of these practices from 1/1/03 to 12/31/05 using billing records

EXCLUSION CRITERIA: Younger than 18 years, had died, or were registered as having a PCP outside of the netw

CRC screening measure included only patients age 52-69 without total colectomy. 

POPULATION CHARACTERISTICS: Physician connected Practice connected 

Mean age & range (years): Sex (% female): Race: 

52 (SD 16.4) 

58.1 

39.9 (15.0) 

56.6 

White 81.2 69.5 

Hispanic Black 

7.0 4.7 

11.2 

6.5 

Asian 4.1 5.6 

Other 1.8 4.2 

Attrition/Drop-out (not available for endpoint measurement): Adherence: 

NA 

Contamination: Response Rates (e.g. for surveys): STATISTICAL ANALYSES: To account for repeated measures of patients from the same physician, the authors used 

equations techniques with compound symmetry correlation structure. Because of the var
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY:	 Authors, ref ID: Atlas4 

Year of publication: 2009 Dates of data collection: 2003 to 2005 Trial name: NR practice was included as a fixed effect in each model. The authors compared proportions of completed performance tests among physician-conconnected patients. 

ASSESSMENT OF EXPOSURES AND POTENTIAL CONFOUNDERS: 

A validated algorithm was used to connect patients to either 1 of 181 physicians or 1 of 13 received most of their care. Patients were classified as “physician-connected”, “practice-c“unconnected”. Only patients in the first 2 groups were analyzed. The algorithm primarily uses the PCP designee field from the hospital registration systemregression model that uses patient age, times since most recent visit, in state residency, a(categorized as the proportion of all visits by patients registered ot he physician). Confounders included age, sex, race/ethnicity, insurance status, and number of visits ove

OUTCOME ASSESSMENT: Outcome Measures: colonoscopy within 10 years; FS or BE within 5 years, home FOBT 

age 52-69 years 

RESULTS: 

C-16KQ2 - What factors influence the use of	 Adjusted rates of CRC screening rates: colorectal cancer screening?	 Physician connected patients: 72.1% (95% CI, 70.5-73.7) 

Practice connected patients: 58.0% (95% CI, 56.7-59.4) P < 0.001 

KQ3 - Which strategies are effective in NA increasing the appropriate use of colorectal cancer screening and followup? KQ4 - What are the current and NA projected capacities to deliver colorectal cancer screening and surveillance at the population level? KQ5 - What are the effective approaches NA for monitoring the use and quality of colorectal cancer screening? QUALITY RATING: Good 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

Quality Assessment-Internal Validity for Observational Studies 

Yes No Other (CD, NR, NA) 

C-17
 

Were the groups similar at baseline regarding the most 

x 

important prognostic indicators? Were the drop-out or response rates acceptable (≤ 20%)? [If NA 

between 20% and 60%, check other and explain.] Were the differential drop-out or response rates acceptable (≤ NA 

15%)? Were intervention/exposure measures valid, reliable, and x equally applied? Were the outcome assessors blinded to the intervention or NR exposure status of subjects? Were outcome measures valid, reliable, and equally applied? x Does the analysis control for baseline differences? x Were important potential confounding and modifying x variables taken into account in the design and analysis (e.g., through matching, stratification, or statistical adjustment)? Were the statistical methods used to assess the abstracted x outcomes appropriate? Quality Rating (Good, Fair, or Poor): Good 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

C-18
 

STUDY:	 Authors, ref ID: Berkowitz, Z., et al.5 

Year of publication: 2008 Dates of data collection: October 2002 to April 2003 Trial name: NA 

OBJECTIVE OR AIM: To assess beliefs and perceptions of risk about colorectal cancer (CRC) and gaps in know

adults aged 65 to 89. 

DESIGN: Setting: United States 

Study design: Cross-sectional retrospective Duration (mean followup): No follow-up Overall study size (N enrolled/N analyzed): 1,148 All 

Sample size: Sample size: 1,148 (583 not up to date with screening) Describe intervention: Intervention: Telephone survey 

RECRUITMENT: Population-based 

(population-based, clinic-based, volunteer, other) INCLUSION CRITERIA:	 No history of CRC, adults aged 65 to 89 

EXCLUSION CRITERIA:	 NR POPULATION CHARACTERISTICS:	 All 

Age range: 65-89 

Mean age & range (years): 

Sex (% female): Race: Other: 

All 

Attrition/Drop-out (not available for response rate for the screening phase of the study was 55% and for the interview phase w

endpoint measurement): overall response rate of 34.5% Adherence: Contamination: Response Rates (e.g. for surveys): STATISTICAL ANALYSES: Describe: 

A separate logistic regression model for each covariate was used to calculate the odds ratup to date with CRC screening, after adjusting for age groups. 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY:	 Authors, ref ID: Berkowitz, Z., et al.5 

Year of publication: 2008 Dates of data collection: October 2002 to April 2003 Trial name: NA Multivariate logistic regression analysis was performed to determine the effect of demogra

characteristics, selected covariates of beliefs and risk perceptions, and knowledge about Cto date with screening. 

ASSESSMENT OF EXPOSURES AND POTENTIAL CONFOUNDERS: OUTCOME ASSESSMENT: Outcome Measures: 

Whether a person had an FOBT in the past year or a colonoscopy/sigmoidoscopy in the pSecondary Outcome: Reasons for Not Being Up to Date with Colorectal Cancer Screening According to Test TyHealth Information National Trends Survey 2003 

RESULTS: 

C-19
 

KQ2 - What factors influence the use of colorectal cancer screening? 

Outcomes: 

In the multivariate analysis, not being up to date with CRC screening was associated with visiting a provider in the previous year, not being able to cite even one test to detect colon arranging to check for colon cancer is difficult or not having an opinion about it, and not hacost of the test (P < 0.03 for each covariate).
 Older patients were more likely than younger patients to be up to date with CRC screening 1.32-2.79; P < 0.001) People who perceived their health to be excellent or very good were no more or less likely screening than those who are in fair or poor health (P = 0.11) 

Respondents who believed that it is not easy to arrange to be tested (AOR, 0.47; 95% CI, are too expensive (AOR, of disagreeing with test being too expensive = 1.25; 95% CI, 0.8knowledge about the number of available tests (AOR, 0.28; 95% CI, 0.19-0.42) were less screened (P values at 0.03 or better) Reasons for not being screened: No recommendation received for 65-74 year olds: FOBT: 87.5% (95% CI, 76.7–93.7%); F(95% CI, 69.3-86.4%) 

For those 75-89 years: FOBT: 84.4% (95% CI, 70.6-92.3%); FS/colonoscopy: 75.9% (95% 

KQ3 - Which strategies are effective in Outcomes: increasing the appropriate use of NA colorectal cancer screening and 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY: Authors, ref ID: Berkowitz, Z., et al.5 

Year of publication: 2008 Dates of data collection: October 2002 to April 2003 Trial name: NA 

followup? KQ4 - What are the current and Outcomes: projected capacities to deliver colorectal cancer screening and surveillance at the population level? 

NA 

KQ5 - What are the effective approaches for monitoring the use and quality of colorectal cancer screening? 

Outcomes: NA 

QUALITY RATING: Fair Quality Assessment-Internal Validity for Observational Studies 

Yes No Other (CD, 

Were the groups similar at baseline regarding the most important prognostic indicators? NA 

Were the drop-out or response rates acceptable (≤ 20%)? [If between 20% and 60%, check other and Response r

explain.] phase of th

the intervieresulting in 34.5% 

Were the differential drop-out or response rates acceptable (≤ 15%)? NA Were intervention/exposure measures valid, reliable, and equally applied? NA Were the outcome assessors blinded to the intervention or exposure status of subjects? NA 

Were outcome measures valid, reliable, and equally applied? X Does the analysis control for baseline differences? X Were important potential confounding and modifying variables taken into account in the design and X 

analysis (e.g., through matching, stratification, or statistical adjustment)? Were the statistical methods used to assess the abstracted outcomes appropriate? X 

Quality Rating (Good, Fair, or Poor): Fair 

C-20
 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

C-21
 

STUDY:	 Authors, ref ID: Cardarelli, R., and Thomas, J.6 

Year of publication: 2009 Dates of data collection: 2004 Trial name: NA 

OBJECTIVE OR AIM: To assess the relationship between having a personal health care provider and receiving 

DESIGN: Setting: United States – 2004 Behavioral Risk Factor Surveillance System data 

Study design: secondary analysis of cross-sectional data Duration (mean followup): NA Overall study size (N enrolled/N analyzed): 144,897 analyzed in descriptive statistics, 1multiple regression models 

Sample size: N = 144,897 (descriptive stats) 

N = 120, 221 (multiple regression 

Describe intervention: models) 

NA 

RECRUITMENT: NA (secondary data analysis; however, the BRFSS participants are a random sample) 

(population-based, clinic-based, volunteer, other) INCLUSION CRITERIA: BRFSS includes civilian, noninstitutionalized adults (1 per household). The dataset in the 

participants who are 50 years or older. 

EXCLUSION CRITERIA:	 NR (no maximum age selected) 

Variable 1 PHP >1 PHP No PHP 

N = 116,349 n = 15,087 n = 13,461 

Age, mean (SD), y 64.7 (10.5) 66.2 (10.6) 61.6 (9.9) 

Female, % 55.8 54.3 43.6 

Non-Hispanic white 80.2 77.3 65.6 

Non-Hispanic 8.0 8.6 10.2 African American Non-Hispanic Other 3.0 3.2 3.9 

Non-Hispanic 1.2 1.7 1.5 multiracial Hispanic 7.6 9.1 18.8 

Education level, % 

Not graduate high 12.4 15.2 21.8 school 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY:	 Authors, ref ID: Cardarelli, R., and Thomas, J.6 

Year of publication: 2009 Dates of data collection: 2004 Trial name: NA 

C-22
 

High school 87.6 84.8 78.2 graduate or greater Income, % <$25,000 30.6 35.7 47.2 

≥$25,000 69.4 64.3 52.8 

Health Insurance, % Yes 94.6 95.2 67.1 

No 5.4 4.8 32.9 

Up-to-date CRC testing, % Yes 59.3 62.5 26.9 

No 40.7 37.5 73.1 

Attrition/Drop-out (not available for BRFSS 2004 mean response rates = 52.7% 

endpoint measurement): Adherence:
 Contamination: Response Rates (e.g. for surveys): STATISTICAL ANALYSES: Descriptive statistics calculated using weighted population percentages. χ2 statistics and 

tested for differences between having a personal health care provider and categorical and Univariate logistic regression analyses used to determine association between dependent variables. Multiple logistic regression analysis used to control for potentially confounding covariates. odds ratios and 95% confidence intervals calculated for the univariate and multiple logistic respectively. Tests for collinearity conducted, and no collinear relationships were identified 

ASSESSMENT OF EXPOSURES AND Multiple logistic regression analysis was used to control for potentially confounding covariPOTENTIAL CONFOUNDERS: Covariates: 

age sex race/ethnicity education level annual household income level having health insurance 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY:	 Authors, ref ID: Cardarelli, R., and Thomas, J.6 

Year of publication: 2009 Dates of data collection: 2004 Trial name: NA 

OUTCOME ASSESSMENT: The outcome of interest was derived from responses to the CRC screening section of the 

asked 4 questions and were considered to be up-to-date if they had a FOBT within the presigmoidoscopy or colonoscopy within the previous 10 years. Responses dichotomized as or “testing not up-to-date.” 

RESULTS: KQ2 - What factors influence the use of colorectal cancer screening? 

Having at least 1 personal health care provider significantly predicted up-to-date CRC tes(OR = 3.96; 95% CI 3.56-4.41) and multiple regression models (OR = 2.91; 95% CI 2.58-3Age (OR = 1.04, 95% CI, 1.04-1.04), sex (female as referent group, OR = 1.13, 95% CI, 1

education (HS+ as referent group, OR = 0.72, 95% CI, 0.65-0.81), income ($25,000+ refe95% CI, 0.64-0.74), and health insurance (No health insurance as referent group, OR = 1were also significantly associated with up-to-date CRC testing. Although covariates were significant predictors, having a personal health care provider hapredicting being up-to-date for CRC testing. 

C-23 KQ3 - Which strategies are effective in NA increasing the appropriate use of 

colorectal cancer screening and followup? KQ4 - What are the current and NA projected capacities to deliver colorectal cancer screening and surveillance at the population level? KQ5 - What are the effective approaches NA for monitoring the use and quality of colorectal cancer screening? QUALITY RATING: Fair 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

Quality Assessment-Internal Validity for Observational Studies 

Yes No Other (CD, NR, NA) 

C-24
 

Were the groups similar at baseline regarding the most NA important prognostic indicators? Were the drop-out or response rates acceptable (≤ 20%)? [If NA - The response rate for the overall BRFSS wa

between 20% and 60%, check other and explain.] chose NA because the current study is secondar

the BRFSS data collected in 2004 

Were the differential drop-out or response rates acceptable (≤ NA 

15%)? Were intervention/exposure measures valid, reliable, and X equally applied? Were the outcome assessors blinded to the intervention or NR exposure status of subjects? Were outcome measures valid, reliable, and equally applied? X Does the analysis control for baseline differences? NA Were important potential confounding and modifying X variables taken into account in the design and analysis (e.g., through matching, stratification, or statistical adjustment)? Were the statistical methods used to assess the abstracted X outcomes appropriate? Quality Rating (Good, Fair, or Poor): Fair 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

C-25
 

STUDY:	 Authors, ref ID: Cairns and Viswanath et al.7 

Year of publication: 2006 Dates of data collection: 2002-2003 Trial name: NR 

OBJECTIVE OR AIM: To examine the role of communication factors and insurance, with a specific focus on the 

disparities in CRC screening. 

DESIGN: Setting: Subgroup analysis of HINTS (a random sample survey of cancer communication 

Study design: Retrospective database analysis of HINTS Duration (mean follow-up): NR Overall study size (N enrolled/N analyzed): 1,253 

Sample size: 1,253 Describe intervention: NA RECRUITMENT: Population-based 

(population-based, clinic-based, volunteer, other) INCLUSION CRITERIA:	 Age 50-64 

EXCLUSION CRITERIA: For “ever screened” for CRC (or screening status), respondents (a) who had CRC, and be

received all survey questions (b) those respondents who did not receive the CRC questio

POPULATION CHARACTERISTICS: 

NR 

Mean age & range (years): 

Sex (% female): Race: Other: Attrition/Drop-out (not available for endpoint measurement): NA Adherence:
 Contamination: Response Rates (e.g. for surveys): NR STATISTICAL ANALYSES: Describe: Survey was conducted by telephone using a list-assisted random-digit-dial sam

and Hispanics were oversampled; therefore screening rates by demographic and health care presented using weighted data that adjusts for this oversampling. All other analyses u

because the enormous sample sizes generated by weighting make it difficult to assess stasmall subpopulation analyses, and create difficulty in modeling with logistic regression. Ausing SPSS version 12.0. 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY:	 Authors, ref ID: Cairns and Viswanath et al.7 

Year of publication: 2006 Dates of data collection: 2002-2003 Trial name: NR 

C-26
 

CRC screening status was examined by demographic variables (age, sex, race/ethnicity) indicators of SES (education, income, employment status and residence in urban or rural identified in the literature as associated with screening behavior in particular and charactehealth services and health access more generally. To provide background on screening rates within subpopulations in the sample, CRC screexamined by demographic variables and usual provider status using crosstabulations, chiKendall’s tau-b correlation coefficients. Because age distributions were not normal, they cscreened and never screened using the nonparametric Mann-Whitney test. To answer first research question (Is insurance status associated with CRC screening, bohaving been screened, and with regard to FOBT being on schedule and repeating screenscreening status by insurance status with a cross-tabulation, chi-square test, and a logistiinsurance status (y/n) as the binomial independent predictor and screening status (ever scdependent variable. On schedule and repeat screening with FOBT were assessed for the insurance status. On schedule screening was based on the USPSTF recommended time FOBT; the proportion that received FOBT within the year before the survey (among those used to assess on schedule screening with FOBT. To assess whether being on schedule for this test was related to insurance status crosstatests were used. To assess repeat screening frequencies were produced of when (categorespondents received another FOBT before their most recent. For patterns in screening bproduced cross-tabulations and chi-square tests for the timing of the most recent FOBT aFOBT before the most recent, overall and by insurance status. To address the 2nd research question (To what extent are communication factors such as 

media, experiences with providers and cancer information seeking related to CRC screening among the uninsured?), authors assessed the relationship between: media atteinformation seeking, patient–provider interaction (CAHPS measures), and provider recom

status among the uninsured by using cross-tabulations, chi-square tests, and Kendall’s taTo examine the 3rd research question (Is provider recommendation, another measure of cassociated with screening among the uninsured?), and because the chi-square statistic wrecommendation, authors generated a logistic regression model with screening status for dependent variable (ever screened = y/n) and provider recommendation as the independecommunication measures were not significant at the bivariate level, and were therefore exmodel. To answer the 4th research question (What are the reasons that deter the uninsured from 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY:	 Authors, ref ID: Cairns and Viswanath et al.7 

Year of publication: 2006 Dates of data collection: 2002-2003 Trial name: NR screening?), authors examined the reasons reported by the uninsured for not undergoing 

uninsured never screened, they combined all reported reasons for not receiving any of the which accounted for the largest proportion of identified barriers: lack of awareness, providproblems or symptoms, and insurance or cost. 

ASSESSMENT OF EXPOSURES AND POTENTIAL CONFOUNDERS: 

HINTS survey collected information on: demographic variables, access to health care, hea

behaviors, knowledge of CRC screening guidelines, beliefs about cancer risk, beliefs abouse, beliefs about cancer in general, “cancer worry”, “degree to which participants paid attmedical topics via television, radio, newspapers, magazines, or the Internet”, trust in infortrust in healthcare providers/family/friends for cancer information, cancer information seekFor this study:
 Independent variables of interest for analysis: lack of insurance & communication Dependent variables: (a) ever screened, and for FOBT, (b) on schedule and repeat scree

OUTCOME ASSESSMENT: Outcome Measures: CRC screening 

C-27 RESULTS: KQ2 - What factors influence the use of 

colorectal cancer screening? 

Outcomes: 

In the sample, 71.2% of respondents reported having undergone at least one kind of CProportion of uninsured who have been screened lower than those who were insured (Screening strongly associated with SES; screening rates increased as income and edudecreased as county of residence became more rural Whites (74.5%) were most likely to have been screened compared to African American(46.6%) Screening rates were higher among insured, and insurance status was a significant preregression model, with the uninsured 64% (95% CI: 0.2451, 0.536) less likely to be scrNo significant association between timing of most recent FOBT and insurance status, b

the uninsured had received only their first FOBT (no prior) compared to the insured More insured respondents repeated FOBT screening (2 consecutive tests), with a 10.7

insured and uninsured There was no statistically significant relationship between any of the communication min the media, cancer information seeking, and patient-provider interactions) and screen
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY:	 Authors, ref ID: Cairns and Viswanath et al.7 

Year of publication: 2006 Dates of data collection: 2002-2003 Trial name: NR 

C-28
 

No communication measures were significantly related to CRC screening status Almost 91% of the uninsured who have received provider recommendation have unde13% of those who did not receive a recommendation by their provider In a simple logistic regression model, this parameter was significant (P < 0.001) and threcommendation were 98.5% (95% CI: 0.003, 0.083) less likely to have ever received who did This parameter was also significant (P < 0.001) when the model was run for the insureinsured who did not receive a provider recommendation 92% (95% CI: 0.054, 0.119) lescreened for CRC Primary reasons reported by the uninsured never screened for not receiving all tests w(35%), lack of provider recommendation (19%), no problems/symptoms (9%), and finano reason reported 36.1% of uninsured received a recommendation versus 62.5% for the insured 

KQ3 - Which strategies are effective in Outcomes: increasing the appropriate use of NA colorectal cancer screening and followup? KQ4 - What are the current and Outcomes: projected capacities to deliver NA colorectal cancer screening and
 surveillance at the population level? KQ5 - What are the effective approaches Outcomes: for monitoring the use and quality of NA colorectal cancer screening? QUALITY RATING: Good 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

Quality Assessment-Internal Validity for Observational Studies 

Yes No 

Were the groups similar at baseline regarding the most important prognostic indicators? 

Were the drop-out or response rates acceptable (≤ 20%)? [If between 20% and 60%, check other and explain.] 

Were the differential drop-out or response rates acceptable (≤ 15%)? Were intervention/exposure measures valid, reliable, and equally applied? Were the outcome assessors blinded to the intervention or exposure status of subjects? X 

Were outcome measures valid, reliable, and equally applied? X Does the analysis control for baseline differences? X Were important potential confounding and modifying variables taken into account in the design and analysis (e.g., X 

through matching, stratification, or statistical adjustment)? Were the statistical methods used to assess the abstracted outcomes appropriate? X 

Quality Rating (Good, Fair, or Poor): Good 

C-29
 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

C-30
 

STUDY:	 Authors, ref ID: Carcaise-Edinboro et al.8 

Year of publication: 2008 Dates of data collection: 2004 Trial name: NA 

OBJECTIVE OR AIM: The relationship between patient-provider communication and socioeconomic variables o

screening using data from the Medical Expenditure Panel Survey. 

DESIGN: Setting: 2004 Medical Expenditure Panel Survey (MEPS) 

Study design: Cross-sectional Duration (mean follow-up): One-time data collection, no follow-up Overall study size (N enrolled/N analyzed): 8,488 

All 

Sample size: Sample size: 8,488 

Intervention: 2004 Medical Expenditure Panel Survey (MEPS) 

Describe intervention: RECRUITMENT: Population-based; 2004 Medical Expenditure Panel Survey (MEPS) (population-based, clinic-based, volunteer, other) INCLUSION CRITERIA:	 Age 50+ 

EXCLUSION CRITERIA:	 NR POPULATION CHARACTERISTICS:	 All
 

Mean age & range (years): NR Sex (% female): Race: Other: 

All 

Attrition/Drop-out (not available for NR endpoint measurement): Adherence: Contamination: Response Rates (e.g. for surveys): STATISTICAL ANALYSES: Describe: 

•	 Authors examined CRC screening status by patient-provider communication 

variables using cross tabulations and x2 tests. 

•	 Using logistic regression models, authors estimated the effects of the patien

patient-provider communication on 3 CRC screening dependent variables. 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY:	 Authors, ref ID: Carcaise-Edinboro et al.8 

Year of publication: 2008 Dates of data collection: 2004 Trial name: NA 

ASSESSMENT OF EXPOSURES AND NR POTENTIAL CONFOUNDERS: OUTCOME ASSESSMENT: Outcome Measures: 

Dependent measures were receipt of CRC screening, fecal occult blood testing, and colon

RESULTS: 

C-31
 

KQ2 - What factors influence the use of colorectal cancer screening? 

Outcomes: 

•	 For the CAHPS patient-provider communication measures, a response of “s

“always” compared with the response of “never” for “adequate time with theipositively and significantly associated with increased screening by all methoFOBT. 

•	 Patients who reported that their provider adequately explained patient health

“sometimes,” “usually,” or “always,” relative to patients who reported their prexplained healthcare needs were significantly more likely to receive CRC sc“Adequate provider explanation of patients’ healthcare needs” was not indep

associated with other forms of CRC screening. 

• Race or ethnicity was not significantly associated with CRC screening in the 

CRC screening by any method: 

•	 Subjects who reported that they sometimes, usually, or always have enough 

were 2.61 (95% CI, 1.55-4.38) to 2.99 (95% CI, 1.83-4.88) times more likely they never have enough time 

For FOBT: 

•	 Subjects who reported that their provider sometimes, usually, or always ade

information were 3.67 (95% CI, 1.16-1.6) to 6.42 (95% CI, 2.15-19.1) times reported provider never explains adequately. 

Logistic regression results for CRC, OR, 95% CI – controlled for age, living area, health stlanguage, source of care, race, ethnicity, sex: 

Independent variable Screened with either c-scope/

Enough time with provider 

Never 

1.0 

Sometimes 2.61 (1.55-4.38) Usually 2.99 (1.83-4.88)  always 2.65 (1.62-4.31) Provider adequately explains Screened with fobt Never 

1.0 

Sometimes 3.67 (1.16-11.6)
 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY: Authors, ref ID: Carcaise-Edinboro et al.8 

Year of publication: 2008 Dates of data collection: 2004 Trial name: NA 

 Usually 6.42 (2.16-19.1) Always 6.09 (2.01-18.4) 

KQ3 - Which strategies are effective in increasing the appropriate use of colorectal cancer screening and followup? 

Outcomes: NA 

KQ4 - What are the current and Outcomes: projected capacities to deliver colorectal cancer screening and surveillance at the population level? 

NA 

KQ5 - What are the effective approaches for monitoring the use and quality of colorectal cancer screening? 

Outcomes: NA 

QUALITY RATING: Fair Quality Assessment-Internal Validity for Observational Studies 

Yes No 

Were the groups similar at baseline regarding the most important prognostic indicators? 

Were the drop-out or response rates acceptable (≤ 20%)? [If between 20% and 60%, check other and 

explain.] Were the differential drop-out or response rates acceptable (≤ 15%)? Were intervention/exposure measures valid, reliable, and equally applied? Were the outcome assessors blinded to the intervention or exposure status of subjects? 

Were outcome measures valid, reliable, and equally applied? X Does the analysis control for baseline differences? X Were important potential confounding and modifying variables taken into account in the design and analysis X 

(e.g., through matching, stratification, or statistical adjustment)? Were the statistical methods used to assess the abstracted outcomes appropriate? X 

Quality Rating (Good, Fair, or Poor): Fair 

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Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY: Can breast and cervical cancer Authors, ref ID: Carlos et al.9 screening visits be used to enhance Year of publication: 2004 colorectal cancer screening? Dates of data collection: 2000 BRFSS data used 

Trial name: NA 

OBJECTIVE OR AIM: Data from the BRFSS were analyzed to identify potential relationships that would allow int

colorectal cancer screening 

DESIGN: Setting: United States 

Study design: cross-sectional Duration (mean follow-up): no f/u data Overall study size (N enrolled/N analyzed): 2,788 women aged 50 or older participated 

All 

Sample size: 1300 respondents, 1488 non-respondents Describe intervention: NA RECRUITMENT: Population based 

(population-based, clinic-based, volunteer, other) 

C-33 INCLUSION CRITERIA: Women 50 years of age or older who participated in the 2000 BRFSS survey and lived in 

administered the colorectal cancer module (CO, IL, MA, OH, UT) 

EXCLUSION CRITERIA: NA POPULATION CHARACTERISTICS:
 

Mean age & range (years): Sex (% female): Race: Other: 

Mean age: 64 years Sex: 100% female Table. Sociodemographic characteristics of women who did and did not respond to colon 

Respondents Nonrespondents 

Characteristic n (%) n (%) Number 1300 (46.6) 1488 (53.4) Age (y) 1300 1486 Mean (range) 64 (50-99) 64 (50-97) ≥50 to <60 546 (42.0) 632 (42.5) ≥60 to <70 366 (28.2) 383 (25.8) ≥70 to <80 251 (19.3) 307 (20.7) ≥80 to <90 121 (9.3) 141 (9.5) ≥90 16(1.2) 23 (1.5) 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY: Can breast and cervical cancer Authors, ref ID: Carlos et al.9 screening visits be used to enhance colorectal cancer screening? 

Year of publication: 2004 Dates of data collection: 2000 BRFSS data used Trial name: NA 

Race Nonwhite and non-Hispanic 118(9.1) 160 (10.8) Income* 1058 1139 <$25,000 396 (37.4) 410 (36.0) 

$25,000-$49,999 385 (36.4) 363 (32.9) $50,000-$74,999 149 (14.1) 168 (14.7) ≥$75,000 128 (12.1) 198 (17.4) 

Educational level achieved' 1298 1486 Attended elementary school or less 48 (3.5) 74 (5.0) Attended at least some high school 567 (43.7) 593 (39.9) 

Attended at least some college or technical school 686 (52.9) 819 (55.1) 

Employment status' 1297 1486 

Unemployed 40(3.1) 29 (2.0) 

Employed or self-employed 505 (38.9) 651 (43.8) Student or homemaker 171 (13.2) 82 (5.5) 

Retired 522 (40.2) 629 (42.3) Unable to work 59 (4.5) 95 (6.4) 

Have health insurance' 1201 (92.4) 1415 (95.1) Cancer screening adherence Colorectal cancer 324 (24.9) Cervical cancer 743 (57.2) 829 (55.7) 

Breast cancer' 1022 (78.6) 1261 (84.7) 

*Denotes a statistically significant difference p < 0.05. 

Attrition/Drop-out (not available for endpoint measurement): Adherence: 

NA 

Contamination: Response Rates (e.g. for surveys): 47% of women surveyed responded to colorectal cancer items! 

C-34
 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY: Can breast and cervical cancer screening visits be used to enhance colorectal cancer screening? 

Authors, ref ID: Carlos et al.9 

Year of publication: 2004 Dates of data collection: 2000 BRFSS data used Trial name: NA 

STATISTICAL ANALYSES: Adherence to the ACS recommendations for CRC screening was considered the primary 

cervical ca screening adherence used as independent predictors of crc screening adherenFirst, univariate analysis evaluated using chi-square. Multivariate analysis subsequently p

C-35
 

ASSESSMENT OF EXPOSURES AND POTENTIAL CONFOUNDERS: 

age, race, educational level, employment status, income, state of origin, health care covethrough telephone interview as part of fixed component of the BRFSS 

OUTCOME ASSESSMENT: Participants asked if they had ever had FOBT, s-scope, c-scope. Those who had undergo

their last test was performed Participants also asked about breast and cervical cancer screening 

RESULTS: KQ2 - What factors influence the use of colorectal cancer screening? Correlates of colon cancer screening adherence 

Variable 

Demographics Unadjusted OR Adjusted OR 

Age (y) (95% el) (95% el) ≥50 to <60 0.50 (0.38-0.66) 

≥60 to <70 1.12 (0.85-1.48) 1.81 (1.16-2.83)* ≥70 to <80 2.04 (1.55-2.74) 3.44 (1.73-6.87)* ≥80 to <90 1.09 (0.72-'1.67) 2.12 (0.95-4.74) 

≥90 1.82 (0.66-5.05) 3.16 (0.68-14.7) 

Nonwhite and non-Hispanic 1.03 (0.67-1.59) 0.93 (0.54-1.61) 

Income <$25,000 1.06 (0.79-1.41) 

$25,000-$49,999 1.09 (0.82-1.47) 1.14 (0.79-1.66) 

$50,000-$74,999 0.83 (0.54-1.26) 1.12 (0.66-1.91) ≥ $75,000 0.89 (0.57-1.39) 1.21 (0.69-2.14) 

Educational level achieved Attended elementary school or less 1.70 (0.97-3.17) 

Attended at least some high school 1.09 (0.84-1.40) 0.65 (0.29-1.45) 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY: Can breast and cervical cancer Authors, ref ID: Carlos et al.9 screening visits be used to enhance colorectal cancer screening? 

Year of publication: 2004 Dates of data collection: 2000 BRFSS data used Trial name: NA 

Attended at least some college or technical school 0.88 (0.66-1.10) 0.50 (0.22-1.14) Employment status Unemployed 0.87 (0.41-1.84) 

Employed or self-employed 0.60 (0.46-0.79)* 0.63 (0.24-1.69) 

Student or homemaker 0.76 (0.50-1.17) 0.50 (0.17-1.46) 

Retired 1.85 (1.44-2.39)* 0.79 (0.28-2.20) 

Unable to work 1.02 (0.56-1.87) 0.70 (0.21-2.28) Have health insurance 3.12 (1.60-6.07)* 2.72 (1.23-6.01)* 

Adherence to non-colorectal cancer-related screening Adherent to Pap smear 0.59 (0.45-0.75)* 2.09 (1.18-3.72)* 

Adherent to mammography 2.37 (1.65-3.41)* 1.89 (1.21-2.92)* 

Note: OR = odds ratio; CI - confidence interval. P < 0.01. 

KQ3 - Which strategies are effective in increasing the appropriate use of colorectal cancer screening and followup? 

Outcomes: NA 

KQ4 - What are the current and Outcomes: projected capacities to deliver colorectal cancer screening and surveillance at the population level? 

NA 

KQ5 - What are the effective approaches for monitoring the use and quality of colorectal cancer screening? 

NA 

QUALITY RATING: Fair 

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Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

Quality Assessment-Internal Validity for Observational Studies 

Yes No Oth

Were the groups similar at baseline regarding the most important prognostic indicators? X Res

sim

Were the drop-out or response rates acceptable (≤ 20%)? [If between 20% and 60%, check other and I do

explain.] res

was 47% comscre

Were the differential drop-out or response rates acceptable (≤ 15%)? See 

Were intervention/exposure measures valid, reliable, and equally applied? X Were the outcome assessors blinded to the intervention or exposure status of subjects? NA 

Were outcome measures valid, reliable, and equally applied? X SelDoes the analysis control for baseline differences? X Were important potential confounding and modifying variables taken into account in the design and X 

analysis (e.g., through matching, stratification, or statistical adjustment)? Were the statistical methods used to assess the abstracted outcomes appropriate? X 

Quality Rating (Good, Fair, or Poor): Fair 

C-37
 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

C-38
 

STUDY:	 Authors, ref ID: Carlos, R.C., et al.10 

Year of publication: 2005 Dates of data collection: 2001 Trial name: NA 

OBJECTIVE OR AIM: To better understand screening behaviors among women, data from the Behavioral Risk F

Survey (BRFSS) were analyzed to identify potential relationships that would allow intervenscreening. 

DESIGN: Setting: U.S. 

Study design: Cross sectional, secondary data analysis 

Duration (mean followup): No follow-up, 2001 Overall study size (N enrolled/N analyzed): 52,478 All 

Sample size: Sample size: 52,478 

No intervention 

Describe intervention: RECRUITMENT: Population-based; BRFFS
 

(population-based, clinic-based, volunteer, other) INCLUSION CRITERIA:	 Women 50 years and older who participated in the BRFSS 2001 survey 

EXCLUSION CRITERIA:	 NR POPULATION CHARACTERISTICS:	 All 

Mean age: 65 

Mean age & range (years): Age range: 50-99 

Sex (% female): 100% female Race: Race: 82% White, Non-Hispanic; 7% Black, nonHispanic; 6% Hispanic, 1% Multiracial, non-Hispanic, 

Other: 3% Other 

All 

Attrition/Drop-out (not available for 97.6% responded to CRC screening items endpoint measurement): Adherence: Contamination: Response Rates (e.g. for surveys): STATISTICAL ANALYSES: Describe: 

• Each potential variable was first screened for its association with cancer scr

• The univariate analysis was evaluated using X 2 test when the variables were 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY: Authors, ref ID: Carlos, R.C., et al.10 

Year of publication: 2005 Dates of data collection: 2001 Trial name: NA 

employment status). 

• Multivariate analysis was subsequently performed using stepwise regression 

ASSESSMENT OF EXPOSURES AND POTENTIAL CONFOUNDERS: 

NR 

OUTCOME ASSESSMENT: Outcome Measures: 

Participants were asked if they had ever had a fecal occult blood test (FOBT), sigmoidoscConsidered the patient compliant if she had an FOBT within the past year or sigmoidoscothe past 5 years. 

RESULTS: 

C-39
 

KQ2 - What factors influence the use of colorectal cancer screening? 

Outcomes: 

Significant demographic factors associated with increased adherence to CRC screen

years old (unadjusted OR, 1.50; P < .01) and 70–79 years old (unadjusted OR, 1.39; 

P < .01) and being white non-Hispanic (unadjusted OR, 1.34; P < .01). 

As income and level of education achieved increased, the likelihood of CRC screenin

< .01). 

Increased screening rates with females who reported adherence to mammograms (A

Pap smears (AOR, 1.70; P < 0.01) 

Females who perceived their health as good were less likely to adhere to CRC scree

(AOR, 0.79; 95% CI, 0.66-0.93; P < 0.01) 

Women who were Hispanic or of other racial/ethnic descent were less likely to have u

(P < .01). 

Those women who were employed or self-employed were also less likely to have und

compared with women who were retired (P < .01). 

Having health insurance (unadjusted OR, 2.70; P < .01) and the presence of a person

OR, 2.89; P < .01) significantly increased the probability of CRC screening. 

Being a current smoker (unadjusted OR, 0.58; P < .01) reduced the probability of CR

KQ3 - Which strategies are effective in Outcomes: increasing the appropriate use of NA colorectal cancer screening and 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY: Authors, ref ID: Carlos, R.C., et al.10 

Year of publication: 2005 Dates of data collection: 2001 Trial name: NA 

followup? KQ4 - What are the current projected capacities to deliver colorectal cancer screening and surveillance at the population level? 

and Outcomes: 

NA 

KQ5 - What are the effective approaches Outcomes: for monitoring the use and quality of NA colorectal cancer screening? QUALITY RATING: Fair 

C-40
 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

Quality Assessment-Internal Validity for Observational Studies 

Yes No Oth

Were the groups similar at baseline regarding the most important prognostic indicators? NA 

C-41
 

Were the drop-out or response rates acceptable (≤ 20%)? [If between 20% and 60%, check other and X 

explain.] Were the differential drop-out or response rates acceptable (≤ 15%)? NA Were intervention/exposure measures valid, reliable, and equally applied? NA Were the outcome assessors blinded to the intervention or exposure status of subjects? NA 

Were outcome measures valid, reliable, and equally applied? X Sig

coloso twinundcoloyea

Does the analysis control for baseline differences? X Were important potential confounding and modifying variables taken into account in the design and X analysis (e.g., through matching, stratification, or statistical adjustment)? Were the statistical methods used to assess the abstracted outcomes appropriate? X 

Quality Rating (Good, Fair, or Poor): Fair 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

C-42
 

STUDY: Colorectal cancer screening Authors, ref ID: Christman et al.11 among a sample of community health Year of publication: 2004 center attendees Dates of data collection: 2002 

Trial name: 

OBJECTIVE OR AIM: To determine the rate of colorectal cancer screening in patients attending a sample of com

medical records of 1,176 patients from eight community health centers were abstracted. 

DESIGN: Setting: community health centers in FL 

Study design: cross-sectional, medical record abstraction Duration (mean follow-up): no f/u data Overall study size (N enrolled/N analyzed): 1,176 medical records from 8 CHC’s 

Overall 

Sample size: 1176 Describe intervention: NA 

RECRUITMENT: Clinics were recruited from among the 16 CHCs participating (population-based, clinic-based, in a county-funded health plan in Hillsborough County, Florida volunteer, other) INCLUSION CRITERIA:	 Clinics were eligible if (1) they provided primary medical care 5 days a week, (2) 

the majority of the clinic staff agreed to participate, and (3) the clinic was expected to continue operating in the same fashion for the following 24 months A patient’s records were eligible to be abstracted if both of the following criteria were met: (1) the patient was 50–75 years of age and (2) the patient was established in the clinic (defined as having made at least one visit 12 months or more before the sampled visit) 

EXCLUSION CRITERIA: Refusal to participate, not open 5 days/week, uncertain if they would operate in a continuo

period of the grant 

POPULATION CHARACTERISTICS: Table. Clinical characteristics of study sample (n = 1176) 

Clinical characteristics n % 

Mean age & range (years): Gender Sex (% female): Race: Male 251 21.3 

Female 925 78.7 

Other: Race/ethnicity African American 341 29 

White 569 48.4 Hispanic 266 22.6 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY: Colorectal cancer screening among a sample of community health center attendees 

Authors, ref ID: Christman et al.11 

Year of publication: 2004 Dates of data collection: 2002 Trial name: 

Attrition/Drop-out (not available for endpoint measurement): Adherence: Contamination: 

NA 

Response Rates (e.g. for surveys): STATISTICAL ANALYSES: The t-test and chi-square test, multivariate predictors of colorectal screening using multipl

Logistic regression models examined the log odds of having obtained any one of the three within the recommended interval. All abstracted variables, including an indicator variable fattended, were eligible for inclusion in the final logistic regression model. The final logistic variables remaining statistically significant at the 0.05 level using a step-wise variable selepredictors of screening odds ratios and 95% confidence intervals. To determine the effectvariables (such as estrogen replacement therapy or having had a PSA screening), logistic gender. 

ASSESSMENT OF EXPOSURES AND POTENTIAL CONFOUNDERS: 

Date of birth; Gender; Marital status; Race; Insurance status; Primary language; # of visits months; # of chronic illnesses listed by physician in chart; chronic illness info for the Charof current medications; smoking status; whether pt had a health maintenance visit in the ppersonal/family h/o breast, cervical, or colorectal cancer screening For women only: h/o hysterectomy, h/o abnormal pap smears, h/o benign breast disease, replacement therapy 

C-43
 

OUTCOME ASSESSMENT: Evidence of the patient having undergone any colorectal screening tests within the recom

time of their audited visit. 

RESULTS: KQ2 - What factors influence the use of Table. Logistic regression of colorectal cancer screening predictors (n = 1168) 

colorectal cancer screening? 

Patients screened for colorectal cancer 

Characteristic n % P 

Gender 0.09 Male 98/251 39 Female 416/925 45 

Race 0.003 White 228/569 40.1 African American 175/341 51.3 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY: Colorectal cancer screening Authors, ref ID: Christman et al.11 among a sample of community health center attendees 

Year of publication: 2004 Dates of data collection: 2002 Trial name: 

Hispanic 111/266 41.7 

Marital status 0.48 Married 147/324 45.4 Unmarried 367/852 43.1 Primary language 0.31 English 414/931 44.5 Non-English 100/245 40.8 

Smoking status 0.4 

Smoker 137/328 41.8 

Nonsmoker 377/848 44.5 Health insurance 0.48 

County program 293/690 42.5 Medicaid 86/180 47.8 

Medicare 104/228 45.6 

Other 31/78 39.7 Family history of colorectal cancer 0.008 Yes 24/37 64.9 No 490/1,139 43 Checkup in past year <0.0001 

Yes 326/627 52 

No 188/549 34.2 Charlson comorbidity index score 0.49 0 185/423 43.7 

1 130/275 47.3 2 113/266 42.5 3+ 86/212 40.6 

KQ3 - Which strategies are effective in increasing the appropriate use of colorectal cancer screening and followup? 

Outcomes: NA 

KQ4 - What are the current and Outcomes: projected capacities to deliver NA 

C-44
 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY: Colorectal cancer screening Authors, ref ID: Christman et al.11 among a sample of community health center attendees 

Year of publication: 2004 Dates of data collection: 2002 Trial name: 

colorectal cancer screening and surveillance at the population level? KQ5 - What are the effective approaches for monitoring the use and quality of colorectal cancer screening? 

Outcomes: NA 

QUALITY RATING: Good Quality Assessment-Internal Validity for Observational Studies 

Yes No 

Were the groups similar at baseline regarding the most important prognostic indicators? 

Were the drop-out or response rates acceptable (≤ 20%)? [If between 20% and 60%, check other and explain.] X 

Were the differential drop-out or response rates acceptable (≤ 15%)? Were intervention/exposure measures valid, reliable, and equally applied? X Were the outcome assessors blinded to the intervention or exposure status of subjects? X Were outcome measures valid, reliable, and equally applied? X Does the analysis control for baseline differences? X Were important potential confounding and modifying variables taken into account in the design and analysis (e.g., X 

through matching, stratification, or statistical adjustment)? Were the statistical methods used to assess the abstracted outcomes appropriate? X 

Quality Rating (Good, Fair, or Poor): Good 

C-45
 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

C-46
 

STUDY:	 Authors, ref ID: Coughlin, S. and Thompson, T.12 

Year of publication: 2005 Dates of data collection: 2000 Trial name: NA 

OBJECTIVE OR AIM: The objective was to determine the proportion of persons who had not received a provide

colorectal cancer screening test according to several characteristics related to socioeconohealth care. 

DESIGN: Setting: United States 

Study design: Cross-sectional (National Health Interview Survey) Duration (mean followup): One-year data collection Overall study size (N enrolled/N analyzed): 12,477/11,480 

Sample size: All 

Sample size: 11,480 

Describe intervention: 

Intervention: None, survey 

RECRUITMENT: Population-based 

(population-based, clinic-based, volunteer, other) INCLUSION CRITERIA:	 Men and women aged 50 years or older who did not have a history of colorectal cancer EXCLUSION CRITERIA:	 Among the persons who did not receive a recent colorectal cancer screening test, a small 

of respondents (n = 14) were excluded whose race was neither White, African American, Native, nor Asian/Pacific Islander. An additional 89 persons (for fecal occult blood test [FOendoscopy) were excluded because they had missing information about reason for not ha

POPULATION CHARACTERISTICS: 

NR 

Mean age & range (years): 

Sex (% female): Race: Other: 

All 

Attrition/Drop-out (not available for Overall response rate of 72.1% endpoint measurement): Adherence: Contamination: Response Rates (e.g. for surveys): 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY: Authors, ref ID: Coughlin, S. and Thompson, T.12 

Year of publication: 2005 Dates of data collection: 2000 Trial name: NA 

STATISTICAL ANALYSES: Describe: 

The descriptive analyses were stratified according to race and ethnicity. A multivariate analysis of predictors of a physician recommendation for each colorectal ca

using logistic regression techniques 

ASSESSMENT OF EXPOSURES AND NR POTENTIAL CONFOUNDERS: OUTCOME ASSESSMENT: Outcome Measures: 

Each adult respondent was asked whether he or she had ever had a sigmoidoscopy, coloand, if so, when they had had their most recent test. For the purposes of this analysis, recent fecal occult blood test use was defined as within flexible sigmoidoscopy or colonoscopy use was defined as within the past 10 years. Lack of doctor recommendation for CRC exams among persons ≥ 50 yrs with no history oInterview Survey, 2000 

RESULTS:

C-47
 

KQ2 - What factors influence the use of colorectal cancer screening? 

Outcomes: Among the men and women who had not had a recent FOBT, reported reasons for not hareason/never thought about it” 51.4% (95% CI 50.0-52.9); “doctor didn’t order it” 22.9% (9

need it/didn’t know I needed this type of test” 12.3% (95% CI 11.4-13.3); “haven’t had any 6.7-8.3); “put it off” 2.0% (95% CI 1.6-2.4); “too expensive/no insurance” 0.5% (95% CI 0.3

unpleasant, or embarrassing” 0.3% (95% CI 0.2-0.5); and “don’t have doctor” 0.4% (95% 

Among the men and women who had a doctor visit in the past year but who had not had a 

about 94.6% (95% CI 94.0-95.2) reported that their doctor had not recommended the tes

Among the persons who had not had a recent endoscopy, the reported reasons for not haor colonoscopy included “no reason/never thought about it” 50.1% (95% CI 48.5-51.7); “do

(95% CI 20.4-22.9); “didn’t need it/didn’t know I needed this type of test” 12.4% (95% CI 1problems” 9.9% (95% CI 8.9-10.9); “put it off” 1.7% (95% CI 1.4-2.1); “too expensive/no in0.8-1.3); “too painful, unpleasant, or embarrassing” 1.3% (95% CI 1.0-1.6); and “don’t hav0.3-0.6). Those persons with no insurance were much more likely to report “never thought about it,insurance,” and “don’t have doctor” as the reason for no endoscopy compared to those wAfter adjustment for age, the factors associated with not receiving a doctor recommendati
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY:	 Authors, ref ID: Coughlin, S. and Thompson, T.12 

Year of publication: 2005 Dates of data collection: 2000 Trial name: NA 

C-48
 

same sample of men and women included the number of children in the household, havinhaving no activity limitations, fewer physician visits in the past year, and residence in the SMultivariate Regression: The factors that were positively associated with a doctor recommincluded female sex, having activity limitations, living in an MSA, or residence outside of t

Doctor Didn’t Recommend FOBT: No., 8,039; %, 94.6; 95% CI, 94.0-95.2; Doctor Didn’t RNo., 6,404; %, 93.5; 95% CI, 92.8-94.2; The results continue to describe differences in wh

recommendation was based on a number of additional factors. Sample includes persons wthe past year but who had not had a home FOBT within the past year or endoscopy within 

KQ3 - Which strategies are effective in Outcomes: 

increasing the appropriate use of NA colorectal cancer screening and
 followup?
 KQ4 - What are the current and Outcomes: projected capacities to deliver NA colorectal cancer screening and
 surveillance at the population level? KQ5 - What are the effective approaches Outcomes: for monitoring the use and quality of NA colorectal cancer screening? QUALITY RATING: Fair 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

Quality Assessment-Internal Validity for Observational Studies 

Yes No 

Were the groups similar at baseline regarding the most important prognostic indicators? 

Were the drop-out or response rates acceptable (≤ 20%)? [If between 20% and 60%, check other and explain.] 

Were the differential drop-out or response rates acceptable (≤ 15%)? Were intervention/exposure measures valid, reliable, and equally applied? Were the outcome assessors blinded to the intervention or exposure status of subjects? 

Were outcome measures valid, reliable, and equally applied? X Does the analysis control for baseline differences? X Were important potential confounding and modifying variables taken into account in the design and analysis (e.g., X 

through matching, stratification, or statistical adjustment)? Were the statistical methods used to assess the abstracted outcomes appropriate? X 

Quality Rating (Good, Fair, or Poor): Fair 

C-49
 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

C-50
 

STUDY:	 Authors, ref ID: Diaz, J.A., Roberts, M.B., Goldman, R.E., Weitzen, S., Eaton, C.B.13 

Year of publication: 2008 Dates of data collection: 2006 Trial name: NA 

OBJECTIVE OR AIM: To examine the relationship between preferred language use (English versus Spanish) an

CRC screening tests among Latinos and non-Latinos. 

DESIGN: Setting: Data from the Centers for 

Study design: Cross-sectional anaDuration (mean followup): NA Overall study size (N enrolled/N a

Disease Control’s 2006 Behavioral Risk Factor Survei

lysis 

nalyzed): 99,895 

Sample size: 

Non-Latino responding-inEnglish Latino responding-in-English Sample size: 3,660 Latino 

Sample si

Sample size: 94,346 Responded to BRFFS Responde

Describe intervention: Responded to BRFFS RECRUITMENT: Population-based (population-based, clinic-based, volunteer, other) INCLUSION CRITERIA:	 Adults at least age 50 years 

EXCLUSION CRITERIA: States that had data on fewer than 50 surveys completed in Spanish were excluded and U

excluded 

POPULATION CHARACTERISTICS:	 Non-Latino responding-in-English Latino responding-in-English Latino re

Mean age: 64.2 Mean age: 61.6 Mean age

Mean age & range (years): Sex: 54.1% Sex: 55.6% Sex: 54.1

Sex (% female): Race: Other: Attrition/Drop-out (not available for NR 

endpoint measurement): Adherence:
 Contamination: Response Rates (e.g. for surveys): STATISTICAL ANALYSES: Describe: 

•	 Respondent characteristics were calculated using standard means for contin

proportions/frequencies for categorical variables. 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY:	 Authors, ref ID: Diaz, J.A., Roberts, M.B., Goldman, R.E., Weitzen, S., Eaton, C.B.13 

Year of publication: 2008 Dates of data collection: 2006 Trial name: NA 

•	 x2 tests were used to examine the relationships between the outcome of int

screening tests, and ethnicity/language category as well as each potential co

•	 Logistic regression was used to estimate crude odds ratios (OR) between th

categories and the receipt of CRC screening tests and to calculate crude ORconfounder variables and receipt of CRC screening tests. 

•	 Variables were considered to be confounders and, hence, included in a fina

model, if the OR for the ethnicity/ language variable adjusted for each potenat least a 10% difference from the crude unadjusted OR. 

ASSESSMENT OF EXPOSURES AND The presence of an identified health care provider, smoking status, and respondent’s perc

POTENTIAL CONFOUNDERS: OUTCOME ASSESSMENT: Outcome Measures:
 

Respondents were considered to have been tested for CRC if they reported completing F1 year or lower endoscopy within the past 10 years. 

RESULTS: 

C-51 KQ2 - What factors influence the use of colorectal cancer screening? Outcomes: •	 There were no significant differences in reported test receipt among groups 

race/ethnicity subgroups 

•	 Overall, 61.6% of non-Latinos versus 43.6% of Latinos reported having rece

test. 

•	 In the adjusted model, compared with non-Latinos, Latinos as a group were 

received CRC screening tests, either FOBT and/or lower endoscopy [adjusteconfidence interval (CI), 0.65-0.85]. 

•	 In the adjusted model, both Latinos responding-in-English (OR, 0.84; 95% C

responding-in-Spanish (OR, 0.57; 95% CI, 0.44-0.74) were less likely to repscreening tests compared with non-Latinos. 

•	 Latinos responding-in-Spanish were 36% less likely than Latinos responding

been screened (OR, 0.64; 95% CI, 0.48-0.84). 

•	 Among those with a health care provider and medical insurance, Latinos res

0.83; 95% CI, 0.71-0.98) and Latinos responding in-Spanish (OR, 0.56; 95% likely to report test use compared with non-Latinos. 

•	 In the low SES strata, compared with non-Latinos, Latinos responding-in-En

0.54-0.91) and Latinos responding in-Spanish (OR, 0.50; 95% CI, 0.39-0.65report CRC test use. In the higher SES strata, although no longer statisticallresponding-in-English (OR, 0.84; 95% CI, 0.70-1.0), Latinos responding-in-Slikely to report screening compared with non-Latinos (OR,0.39; 95% CI, 0.24

KQ3 - Which strategies are effective in Outcomes: increasing the appropriate use of NA 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY:	 Authors, ref ID: Diaz, J.A., Roberts, M.B., Goldman, R.E., Weitzen, S., Eaton, C.B.13 

Year of publication: 2008 Dates of data collection: 2006 Trial name: NA 

C-52
 

colorectal cancer screening and followup? KQ4 - What are the current and Outcomes: projected capacities to deliver NA colorectal cancer screening and
 surveillance at the population level?
 KQ5 - What are the effective approaches Outcomes: for monitoring the use and quality of NA colorectal cancer screening? QUALITY RATING: Good 

Quality Assessment-Internal Validity for Observational Studies 

Yes No Ot

Were the groups similar at baseline regarding the most important prognostic indicators? X 

Were the drop-out or response rates acceptable (≤ 20%)? [If between 20% and 60%, check other and NR 

explain.] Were the differential drop-out or response rates acceptable (≤ 15%)?	 NR 

Were intervention/exposure measures valid, reliable, and equally applied? NA 

Were the outcome assessors blinded to the intervention or exposure status of subjects? NA 

Were outcome measures valid, reliable, and equally applied? X Th

siginc

Does the analysis control for baseline differences? X 

Were important potential confounding and modifying variables taken into account in the design and analysis X 

(e.g., through matching, stratification, or statistical adjustment)? Were the statistical methods used to assess the abstracted outcomes appropriate? X 

Quality Rating (Good, Fair, or Poor): Good 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

C-53
 

STUDY:	 Authors, ref ID: Etzioni, D., et al. 14 Year of publication: 2004 

Dates of data collection: 2001 Trial name: NA 

OBJECTIVE OR AIM: The authors used the 2001 California Health Interview Survey (CHIS 2001) to evaluate 1) 

predictors of the receipt of tests, and 3) reasons for nonuse of CRC tests. 

DESIGN: Setting: California 

Study design: Cross-sectional study Duration (mean followup): One year Overall study size (N enrolled/N analyzed): 22,343 

Sample size: All 

Sample size: 22,343 

Describe intervention: Intervention: None, survey (CHIS) RECRUITMENT: Population-based, California (California Health Interview Survey) 

(population-based, clinic-based, volunteer, other) INCLUSION CRITERIA:	 Individuals age 50+ years without a personal history of CRC 

EXCLUSION CRITERIA: Respondents for whom receipt of a colorectal test could not be determined as a result of h

or “don’t know” to questions concerning testing. 

POPULATION CHARACTERISTICS:	 All 

Age: 54.7% 50-64, 45.3% 65+ 

Mean age & range (years): Sex: 59.9% Female Sex (% female): Race: 80.4% White, 6.4% Latino, 4.5% Asian, 4.7% African Americna, 2.6% Race: Other, 1.5% American Indian/Alaska Native Other: 

All 

Attrition/Drop-out (not available for NA endpoint measurement): Adherence: Contamination: Response Rates (e.g. for surveys): 63.7% 

STATISTICAL ANALYSES: Describe: 

Weighted multivariate logistic regression was used to analyze each respondent’s likelihooCRC testing. Two regression models were estimated, 1 for respondents ages 50–64 yearage >65 years, to account for age-related differences in health insurance coverage. 

ASSESSMENT OF EXPOSURES AND NR POTENTIAL CONFOUNDERS: 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY:	 Authors, ref ID: Etzioni, D., et al. 14 Year of publication: 2004 

Dates of data collection: 2001 Trial name: NA 

OUTCOME ASSESSMENT: Outcome Measures:
 

Survey respondents were considered tested if an FOBT was performed in the 12 months either a flexible sigmoidoscopy or colonoscopy was performed within 5 years prior to the i

RESULTS: 

C-54
 

KQ2 - What factors influence the use of colorectal cancer screening? 

Outcomes: 

•	 Men in both age groups were more likely to be tested than women. This effe

respondents ages 50–64 years (RR, 1.28; 95% CI, 1.23–1.32) than in respo

(RR, 1.19; 95% CI, 1.15–1.23). Among respondents age > 65 years, increaspositively with screening (RR for 5-year interval, 1.49; 95% CI, 1.43–1.57). 

•	 In respondents age > 65 years, this effect reversed direction—older respond

screened (RR for 5-year interval, 0.91; 95% CI, 0.88–0.94). 

•	 Among adults age ≥ 65 years, Latinos were the only racial/ethnic group tha

likely than whites to have received recent testing (RR, 0.84; 95% CI, 0.77– 00.62; 95% CI 0.37-0.92 for 65+ yrs). 

•	 Respondents living below the FPL were significantly less likely to be tested t

group (RR, 0.81; 95% CI, 0.72– 0.91). 

•	 Health insurance status was a significant predictor of likelihood of testing in 

Uninsured individuals with a USOC, however, were much less likely to have individuals who had employer-based insurance with a USOC (RR, 0.61; 95% Uninsured with no USOC less likely to be screened than any of the other gro0.32; 95% CI 0.23-0.43 for 50-64; RR, 0.08; 95% CI, 0.00-1.21 for 65+). 

•	 Respondents who reported visiting a physician 1 or more times in past year 

being current with screening (RR range 1.41-1.77) 

•	 Among adults age ≥ 65 years, individuals with fair or poor health status were 

than individuals with good, very good, or excellent health status (RR, 0.92; 9

•	 Individuals age > 65 years who were recent immigrants to the U.S. (0–50% 

less likely to be tested than lifetime U.S. residents (RR, 0.86; 95% CI, 0.76–

•	 Reported reasons for not having endoscopic testing differed by race and eth

were significantly more likely than whites to report that they were not tested symptoms or perceived health problems (Asians, 31%; Latinos, 29%; whites

same groups were less likely than whites to report that they were not tested examination was painful or embarrassing (Asians, 3%; Latinos, 3%; whites, 

their physician did not tell them the test was needed (Asians, 21%; Latinos, 

0.001). 

•	 The reasons reported for not undergoing endoscopic examination also varie

•	 The reasons identified for not having an FOBT were similar to the reasons fo

endoscopic screening tests, with lack of physician recommendation the mosby all groups. 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY:	 Authors, ref ID: Etzioni, D., et al. 14 Year of publication: 2004 

Dates of data collection: 2001 Trial name: NA 

KQ3 - Which strategies are effective in Outcomes: 

increasing the appropriate use of NA
 colorectal cancer screening and
 followup?
 KQ4 - What are the current and Outcomes: projected capacities to deliver NA colorectal cancer screening and
 surveillance at the population level? KQ5 - What are the effective approaches Outcomes: for monitoring the use and quality of NA colorectal cancer screening? QUALITY RATING: Fair 

C-55
 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

Quality Assessment-Internal Validity for Observational Studies 

Yes No Ot

Were the groups similar at baseline regarding the most important prognostic indicators? NA 

Were the drop-out or response rates acceptable (≤ 20%)? [If between 20% and 60%, check other and NR 

explain.] Were the differential drop-out or response rates acceptable (≤ 15%)? NA 

Were intervention/exposure measures valid, reliable, and equally applied? NA Were the outcome assessors blinded to the intervention or exposure status of subjects? NA 

Were outcome measures valid, reliable, and equally applied? X Does the analysis control for baseline differences? X Were important potential confounding and modifying variables taken into account in the design and analysis X 

(e.g., through matching, stratification, or statistical adjustment)? Were the statistical methods used to assess the abstracted outcomes appropriate? X 

Quality Rating (Good, Fair, or Poor): Fair 

C-56
 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

C-57
 

STUDY: Authors, ref ID: Fenton, J.J., et al.15 

Year of publication: 2007 Dates of data collection: 2002-2003 Trial name: NA 

OBJECTIVE OR AIM: Determine the association between receipt of a periodic health examination (PHE) and co

in enrollees in a prepaid health plan who were eligible for CRC, breast cancer, or prostate 

DESIGN: Setting: Clinic 

Study design: Retrospective cohort study Duration (mean followup): No follow-up, compared 2000-2001 screening rates to those 

Overall study size (N enrolled/N analyzed): 64,288 patients 

Sample size: PHE No PHE 

Sample size: 33,708 Sample size: 30,580 

Describe intervention: Intervention: Received a periodic 

health examination between 2002­2003 

RECRUITMENT: Participants were enrolled in Group Health Cooperative, a mixed-model health plan that s

(population-based, clinic-based, 000 enrollees in Washington State.
 volunteer, other) INCLUSION CRITERIA:	 Enrolled in Group Health Cooperative, 52 to 78 years on January 1, 2002, eligible for CRC

prostate cancer screening in 2002-2003 based on health care data from previous enrollmehistory of CRC , 1 or more primary care visits from 2002-2003 

EXCLUSION CRITERIA:	 Received no primary care visits during the study period; Sigmoidoscopy, colonoscopy, or 

1997-2001; Any positive fecal occult blood test results, 1997-2001; Known indications for colonoscopy, 1997-2001 

POPULATION CHARACTERISTICS:	 PHE No PHE 

Age range: 52-78 Age range: 52-78 

Mean age & range (years): 60.1% female 47% female 

Sex (% female): Race: Other: 

Group 1 

Attrition/Drop-out (not available for endpoint measurement): NA Adherence: Contamination: Response Rates (e.g. for surveys): NA 

STATISTICAL ANALYSES: Describe: 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY: Authors, ref ID: Fenton, J.J., et al.15 

Year of publication: 2007 Dates of data collection: 2002-2003 Trial name: NA 

C-58
 

•	 Used multivariate logistic regression to estimate adjusted incidence differenc

of testing in patients who did and did not receive a PHE. 

•	 In adjusted models, authors set covariates to sample means to enable mode

direct adjustment and estimated confidence intervals (CIs) using bootstrap p

•	 Modeled completion of testing as a function of PHE receipt while adjusting fo

sex (for CRC testing), comorbidity (Charlson comorbidity index score of 0, 1

outpatient visits (quintiles), baseline PHE receipt, baseline number of target >2), benign prostatic hyperplasia diagnosis in 2000-2003 (for prostate canceinteractions between PHE receipt and covariates as identified by likelihood r

•	 Used the models to estimate adjusted cancer testing incidences among part

not receive a PHE stratified by age, sex (for CRC testing), and the number o

•	 Of those who received a PHE, 57.2% received CRC testing vs. 17.2% of tho

PHE 

ASSESSMENT OF EXPOSURES AND • “If patients often receive opportunistic prevention outside of preventive visits

POTENTIAL CONFOUNDERS: association between PHE receipt and cancer testing to weaken in patients w

•	 An association between the PHE and cancer screening could arise if patient

request the desired screening. 

OUTCOME ASSESSMENT: Outcome Measures: 

•	 Completion of any colorectal cancer testing in 2002-2003 

•	 A PHE was defined as any outpatient encounter in 2002-2003 having either 

management code indicating “initial evaluation” (codes 99386-7) or “reevaluhealthy individual” (codes 99396-7) or (2) an International Classification of DClinical Modification, code signifying either a general medical (code V700 or (code V723) examination. 

RESULTS: KQ2 - What factors influence the use of Outcomes: 

colorectal cancer screening? • Of those received a PHE, 57.2% received CRC testing vs. 17.2% of those w

•	 The incidence of CRC testing was more than 3 times higher in patients who 

those who did not (adjusted relative incidence, 3.47; 95% CI, 3.34-3.59; P < 

•	 Stratified by the number of outpatient visits, there remained substantial diffe

testing incidences between patients who did and did not receive PHEs, even highest quintile of visits. 

KQ3 - Which strategies are effective in Outcomes: 

increasing the appropriate use of NA colorectal cancer screening and
 followup?
 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY: Authors, ref ID: Fenton, J.J., et al.15 

Year of publication: 2007 Dates of data collection: 2002-2003 Trial name: NA 

KQ4 - What are the current and Outcomes: projected capacities to deliver colorectal cancer screening and surveillance at the population level? 

NA 

KQ5 - What are the effective approaches for monitoring the use and quality of colorectal cancer screening? 

Outcomes: NA 

QUALITY RATING: Fair Quality Assessment-Internal Validity for Observational Studies 

Yes No Other (CD, NR, N

Were the groups similar at baseline regarding the most important prognostic Somewhat indicators? Were the drop-out or response rates acceptable (≤ 20%)? [If between 20% and NA 

60%, check other and explain.] Were the differential drop-out or response rates acceptable (≤ 15%)? NA 

Were intervention/exposure measures valid, reliable, and equally applied? X Were the outcome assessors blinded to the intervention or exposure status of NR 

subjects? Were outcome measures valid, reliable, and equally applied? X Does the analysis control for baseline differences? X Were important potential confounding and modifying variables taken into account in X the design and analysis (e.g., through matching, stratification, or statistical adjustment)? Were the statistical methods used to assess the abstracted outcomes appropriate? X 

Quality Rating (Good, Fair, or Poor): Fair 

C-59
 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY:	 Authors, ref ID: Fenton et al.(#3677} 

Year of publication: 2009 Dates of data collection: 1995 - 2003 Trial name: Persistent Racial and Ethnic Disparities in Up –to-Date Colorectal Cancer Te

OBJECTIVE OR AIM: To assess whether greater colonoscopy use among white as compared with nonwhite Me

Medicare established coverage for colorectal cancer screening has been associated with nonwhite disparities in up-to-date CRC testing status 

DESIGN: Setting: Medicare claims (Surveillance, Epidemiology, and End Results (SEER) regions i

14% of the US population Study design: cross-sectional (serial) Duration (mean follow up): NA Overall study size (N enrolled/N analyzed): 60,450 

C-60
 

Sample size: Describe intervention: 

Demographics from a single six-month sample (January 1, 2000 to June 30, 2000) N=60,450 Age 70 – 74 years 50.9% Age 75 – 79 years 49.1% Female 58.7% Male 41.3% White 85.8% (n=51,865) Black 6.7% (n=4,042) Asian/Pacific Islander 4.7% (n=2,845) Hispanic 2.8% (n=60,450) Intervention: NA 

RECRUITMENT: (population-based, clinic-based, volunteer, other) INCLUSION CRITERIA: 

Groups were created every six months from July 1995 to December 2003 from the annuaMedicare enrollees in SEER regions; data were obtained from 12 registries in nine states. Part A and Part B Medicare fee-for-service enrollees aged 70 – 79 years 

EXCLUSION CRITERIA: Age > 80 years; history of colon cancer (excluded only during the year of diagnosis and fo

“Native American,” “missing,” or “other” designation for race; Medicaid managed care enro

POPULATION CHARACTERISTICS: NA Mean age & range (years): Sex (% female): Race: 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY: Authors, ref ID: Fenton et al.(#3677} 

Year of publication: 2009 Dates of data collection: 1995 - 2003 Trial name: Persistent Racial and Ethnic Disparities in Up –to-Date Colorectal Cancer Te

Other: 

Groups were identified every six months from July 1995 to December 2003. For each six

Attrition/Drop-out (not available for endpoint measurement): Adherence: 

104,000 Medicare enrollees between the ages of 70 – 79 were considered for inclusion (rFor each six-month period, the number included in the analysis fell between 55.7% in late 

Contamination: Response Rates (e.g. for surveys): STATISTICAL ANALYSES: Describe: 

•	 Conditional prediction was used to estimate and compare race- and eth

adjusting for independent variables 

•	 To model binary outcome of up-to-date status, generalized estimating e

perform repeated-measures logistic regression in which the referent group wobservation period. The model included indicator variables for each race and fixed at the mean values observed across the entire sample. 

•	 Two sensitivity analyses were conducted to assess the effect of alterna

date” status

C-61
 ASSESSMENT OF EXPOSURES AND NA 

POTENTIAL CONFOUNDERS: OUTCOME ASSESSMENT: Outcome Measures: 

Overall up-to-date status Up-to-date status per test method 

RESULTS: KQ2 - What factors influence the use of colorectal cancer screening? 

Outcomes: 

•	 The percent of Medicare enrollees who were up to date with CRC testing inc

racial and ethnic categories from mid-1995 through 2003 

•	 White vs. non-white differences persisted, but did not widen from late 1995 t

in up-to-date status narrowed for each non-white group. The difference betwdid not change until late 2003 when it dropped from 15.7% to 14.1% 

•	 In each racial and ethnic group, the percentage of up-to-date by FOBT and t

date by sigmoidoscopy declined from mid 1995 through 2003. 

•	 The percentage of up-to-date by colonoscopy increased during the study pe•	 Disparities in the overall up-to-date status changed little during the study pe•	 Whites exhibited a greater decline in up-to-date status for FOBT and sigmoi

and ethnic groups. Whites showed a greater increase in up-to-date status foracial/ethnic groups. 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY: Authors, ref ID: Fenton et al.(#3677} 

Year of publication: 2009 Dates of data collection: 1995 - 2003 Trial name: Persistent Racial and Ethnic Disparities in Up –to-Date Colorectal Cancer Te

KQ3 - Which strategies are effective in NA increasing the appropriate use of colorectal cancer screening and followup? KQ4 - What are the current and NA projected capacities to deliver colorectal cancer screening and surveillance at the population level? KQ5 - What are the effective approaches NA for monitoring the use and quality of colorectal cancer screening? QUALITY RATING: Fair 

C-62
 
C-63
 

Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) Quality Assessment-Internal Validity for Observational Studies 

Yes No Other (CD, NR, N

Were the groups similar at baseline regarding the most important prognostic NA indicators? Were the drop-out or response rates acceptable (≤ 20%)? [If between 20% and NA 

60%, check other and explain.] Were the differential drop-out or response rates acceptable (≤ 15%)? NA 

Were intervention/exposure measures valid, reliable, and equally applied? NA Were the outcome assessors blinded to the intervention or exposure status of NA 

subjects? Were outcome measures valid, reliable, and equally applied? X Does the analysis control for baseline differences? X Were important potential confounding and modifying variables taken into account in X the design and analysis (e.g., through matching, stratification, or statistical adjustment)? Were the statistical methods used to assess the abstracted outcomes appropriate? X There is no statem

statistical significachanges/differencresults. 

Quality Rating (Good, Fair, or Poor): Fair 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY: Authors, ref ID: Ferrante et al.16 

Year of publication: 2006 Dates of data collection: April 2003 - December 2004 Trial name: NA 

OBJECTIVE OR AIM: The objective of this study was to examine whether obesity is associated with lower rates 

screening among patients in primary care practices. 

DESIGN: Setting: 22 family medicine practices (20 group practices; 2 solo practices) located in New 

Pennsylvania Study design: Cross-sectional retrospective (medical record chart abstraction) 

Duration (mean follow-up): NA Overall study size (N enrolled/N analyzed): 1297 patients eligible for colorectal cancer patient population of 2034. 

Sample size: 

Describe intervention: 

C-64
 

All 1297 Colorectal cancer screening was documented by searching the medical record for any dobeing done including: progress reports, preventative flow sheets, lab tests, X-rays, and cowere considered to have been screened according to guidelines (1=yes, 0=no) if they had medical record of having received one of the following tests in the recommended time perrecommendations from the American Cancer Society (ACS): (1) FOBT within 1 year, (2) syears, (3) colonoscopy within 10 years, or (4) double contrast barium enema within 5 year

RECRUITMENT: (population-based, clinic-based, volunteer, other) 

Clinic-based; Participating practices generated lists of patients seen in the office during th

using ICD-9 codes for asthma, coronary heart disease, diabetes, hypertension, and any repractice about 100 patients were randomly selected (20 from each list of patients, based orequirements for ULTRA (Using Learning Teams for Reflective Adaptation)). In practices patients with a particular ICD-9 code, all patients with the code were used. For all patient

from the research team noted the dates of relevant cancer screenings using a standardize

INCLUSION CRITERIA: Patients aged 50 years and over. EXCLUSION CRITERIA: Patients were excluded if they were deceased at the time of the audit, below 18 years of a

the practice. 

POPULATION CHARACTERISTICS: Group 1 (non-obese) Group 2 (obese) Mean age & range (years): Sex (% female): Race: 

68.71 (60.8%) 

60% female 

NR 

63.47 (39.2%) 

40% female 

NR 

80% Wh

3% Pac

Other: 

70.9% colonoscopy, 25% FOBT, 75.2% colonoscopy, 16.8% FOBT, 72.4% c

11.1% sigmoidoscopy, 2.9% barium 13.1% sigmoidoscopy, 1.5% barium 11.8% si

enema enema 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY: Authors, ref ID: Ferrante et al.16 

Year of publication: 2006 Dates of data collection: April 2003 - December 2004 Trial name: NA 

C-65
 

64% 

Medi

Attrition/Drop-out (not available for endpoint measurement): Adherence: Contamination: 

Group 1 

NA 

Group 2 

NA 

Response Rates (e.g. for surveys): STATISTICAL ANALYSES: Describe: 

•	 Obese and non-obese patients were compared with respect to potential con

calculating frequencies or means with standard deviations, depending on whcategorical or continuous, respectively, for each group of patients. 

•	 Significant differences between the two groups were determined by Chi squ

•	 Conducted bivariate analysis to assess the relationship between each of the 

with colorectal cancer screening. 

•	 Conducted multivariate analysis to control for potential confounders. •	 Hierarchical logistic regression was used to account for clustering of patients 

examine whether obesity status of the patient was associated with difference

•	 Controlled for effects of age, gender, number of visits in the last 2 years, num

number of years attending the practice. 

•	 Generalized estimating equations were used for estimation, using an exchan

structure for the working correlation matrix. 

•	 Analyzed data separately for men and women to see if obesity-related scree

gender 

•	 Computed adjusted odds ratios and 95% confidence intervals. 

ASSESSMENT OF EXPOSURES AND • Controlled for effects of age, gender, number of visits in the last 2 years, num

POTENTIAL CONFOUNDERS: number of years attending the practice. 

•	 Did not have data on SES of patients but used health insurance as a crude 

homogenous population of predominately white suburban patients made it leassociations found in this study would be confounded by SES. 

OUTCOME ASSESSMENT: Outcome Measures:
 

Patients (obese and non-obese) were considered to have been screened according to guthey had documentation in the medical record of having received one of the following testperiod based on recommendations from the American Cancer Society (ACS): (1) FOBT w
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY: Authors, ref ID: Ferrante et al.16 

Year of publication: 2006 Dates of data collection: April 2003 - December 2004 Trial name: NA sigmoidoscopy within 5 years, (3) colonoscopy within 10 years, or (4) double contrast bar

RESULTS: KQ2 - What factors influence the use of Outcomes: colorectal cancer screening? • 31% of non-obese patients were screened for CRC compared with 27% of o

• 34% of male patients were screened for CRC compared with 25% of female • Patients who were screened for CRC had higher mean number of visits in th

with those who were not screened (P = 0.0179). 

• After controlling for age, gender, total number of comorbidities, number of vi

number of years attending the practice, obese patients had 25% decreased CRC compared to non-obese patients (AOR 0.75’ 95% CI, 0.62-0.91), P = 0

• Despite more frequent visits, obese patients were less likely to be screened 

• After control for age, obesity, total number of co-morbidities, and number of 

men had 53% increased odds of receiving CRC screening compared to wom

• After adjusting for other covariates, each 1-unit increase in number of visits 

associated with a 4% increase in odds of receiving CRC screening (P = 0.00

• Stratified analysis showed no interaction with obesity and gender in CRC sc

• Odds of screening when obese versus non-obese for men and women were 

and 0.77 (95% CI: 0.57, 1.05), respectively. 

KQ3 - Which strategies are effective in increasing the appropriate use of colorectal cancer screening and followOutcomes: NA up? KQ4 - What are the current and Outcomes: projected capacities to deliver colorectal cancer screening and 

NA 

surveillance at the population level? KQ5 - What are the effective approaches for monitoring the use and quality of colorectal cancer screening? 

Outcomes: NA 

QUALITY RATING: Fair 

C-66
 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

Quality Assessment-Internal Validity for Observational Studies 

Yes No Other (CD, NR

Were the groups similar at baseline regarding the most important prognostic indicators? NA 

Were the drop-out or response rates acceptable (≤ 20%)? [If between 20% and 60%, check other they reviewed 

and explain.] charts Were the differential drop-out or response rates acceptable (≤ 15%)? NA Were intervention/exposure measures valid, reliable, and equally applied? X Were the outcome assessors blinded to the intervention or exposure status of subjects? X one nurse revi

blinded 

Were outcome measures valid, reliable, and equally applied? X Patients (obes

considered to haccording to guif they had docrecord of havinfollowing tests period based othe American CFOBT within 1 within 5 years, years, or (4) doenema within 5 

Does the analysis control for baseline differences? X Were important potential confounding and modifying variables taken into account in the design and X 

analysis (e.g., through matching, stratification, or statistical adjustment)? Were the statistical methods used to assess the abstracted outcomes appropriate? X 

Quality Rating (Good, Fair, or Poor): Fair 

C-67
 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

C-68
 

STUDY:	 Authors, ref ID: Fisher, D.A., et al.17 

Year of publication: 2006 Dates of data collection: March 1, 2000 and February 28, 2001 Trial name: NA 

OBJECTIVE OR AIM: The primary aim of this study was to explore the factors associated with undergoing a full 

a positive fecal occult blood test (FOBT) in a single Veterans Affairs center. (of note, the sprimary question, was based on testing for a difference between subjects by race) 

DESIGN: Setting: Durham Veterans Affairs Medical Center (Durham, NC) 

Study design: Cross-sectional, retrospective medical record review of patients with + FODuration (mean followup): 12 months Overall study size (N enrolled/N analyzed): 538 Overall 

Sample size: Sample size: 538 Describe intervention: NA (not an intervention study) 

RECRUITMENT: Clinic-based (Durham Veterans Affairs Medical Center (Durham, NC)) 

(population-based, clinic-based, volunteer, other) INCLUSION CRITERIA: Had a positive FOBT that was ordered from a primary care clinic between March 1, 2000 

if they were at least 50 years of age 

EXCLUSION CRITERIA: Patients who had undergone colonoscopy or DCBE within the prior 5 years and those who 

the FOBT result date; are other than Caucasian or African American 

POPULATION CHARACTERISTICS: Overall Mean age & range (years): Sex (% female): Race: 

Mean Age: 67.2 (range NR) Sex: 1.9% female Race: 58% White, 28.6% Black, 

Other: 13.4% Missing Attrition/Drop-out (not available for NA endpoint measurement): Adherence:
 Contamination: Response Rates (e.g. for surveys): NA 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY:	 Authors, ref ID: Fisher, D.A., et al.17 

Year of publication: 2006 Dates of data collection: March 1, 2000 and February 28, 2001 Trial name: NA 

STATISTICAL ANALYSES: Describe: 

•	 Descriptive statistics were computed for age, gender, race, marital status, ap

referral to gastroenterology. 

•	 They conducted bivariate analyses of predictor variable with our primary out

•	 For these unadjusted analyses, they used x2 tests (or exact tests) to examin

adherence, and referral to gastroenterology in the proportion of patients with 

•	 A two-sample t test was used to examine differences in age between those 

that did not. 

•	 For the adjusted analysis they used logistic regression models to evaluate fa

within 12 months. Factors were included in the logistic regression model if thFCE was significant (P < 0.05). 

ASSESSMENT OF EXPOSURES AND POTENTIAL CONFOUNDERS: 

Regressions included factors in the model if the bivariate association with FCE was signifreferral for GI, and no show/cancel variables; did not include gender or marital status) SES, education, and whether subjects have other sources of care (besides the VA) were To avoid bias resulting from potential seasonal variation in patient evaluation (such as houevaluated the medical records of all patients over a 12-month consecutive period who me

C-69
 

OUTCOME ASSESSMENT: Outcome Measures: 

•	 The primary outcome, full colon evaluation, was defined as having a colonos

barium enema plus flexible sigmoidoscopy completed within 12 months. 

•	 As a secondary outcome, FCE was defined as colonoscopy or DCBE alone. 

RESULTS: KQ2 - What factors influence the use of colorectal cancer screening? 

Outcomes: 

•	 77% of subjects were referred to gastroenterology 

•	 Ultimately, 44% underwent FCE within 12 months 

•	 In the unadjusted analysis, referral to gastroenterology consult was strongly 

evaluation (FCE) (P < 0.001). 

•	 57% (237 of 415) of the subjects referred for gastroenterology consult under

months compared with 0% (0 of 123) of the subjects who were not referred fconsult. 

•	 In both the unadjusted and adjusted analyses, adherence to follow-up appoi

with FCE (P < 0.001); adjusted OR for no show/cancel 0.06, 95% CI: 0.03, 0

•	 Although the subjects with missing race seemed less likely to undergo FCE 

race data, they found no association between Blacks vs. Whites and perform1.14, 95% CI: 0.75, 1.75) 

•	 Blacks were as likely to receive full colon examination as whites (AOR, 1.14
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY:	 Authors, ref ID: Fisher, D.A., et al.17 

Year of publication: 2006 Dates of data collection: March 1, 2000 and February 28, 2001 Trial name: NA 

KQ3 - Which strategies are effective in Outcomes: 

increasing the appropriate use of
 colorectal cancer screening and
 followup?
 KQ4 - What are the current and Outcomes: projected capacities to deliver colorectal cancer screening and
 surveillance at the population level?
 KQ5 - What are the effective approaches Outcomes: for monitoring the use and quality of colorectal cancer screening?
 QUALITY RATING: Fair 

C-70
 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

Quality Assessment-Internal Validity for Observational Studies 

Yes No Ot

Were the groups similar at baseline regarding the most important prognostic indicators? NA 

Were the drop-out or response rates acceptable (≤ 20%)? [If between 20% and 60%, check other and NA 

explain.] Were the differential drop-out or response rates acceptable (≤ 15%)? NA 

Were intervention/exposure measures valid, reliable, and equally applied? X Were the outcome assessors blinded to the intervention or exposure status of subjects? NR 

Were outcome measures valid, reliable, and equally applied? X Does the analysis control for baseline differences? X Were important potential confounding and modifying variables taken into account in the design and analysis X X Se(e.g., through matching, stratification, or statistical adjustment)? (some su

were) wh

so

Were the statistical methods used to assess the abstracted outcomes appropriate? X 

Quality Rating (Good, Fair, or Poor): Fair 

C-71
 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

C-72
 

STUDY:	 Authors, ref ID: Fox et al.18 

Year of publication: 2009 Dates of data collection: not reported Trial name: Cancer screening adherence: Does physician-patient communication matter? 

OBJECTIVE OR AIM: To examine the separate contributions of patients and physicians to their communication 

screening. To formulate a conceptual framework to explicate whether and how communicand their patients influenced patient behavior. To test the hypothesis that physician-patien

cancer screening promoted patient adherence to cancer screening recommendations. 

DESIGN: Setting: community-based primary care facilities 

Study design: cross-sectional survey Duration (mean follow up): NA Overall study size (N enrolled/N analyzed): after a phased identification and selection 904 of their patients were surveyed 

Sample size: 63 physicians 

904 patients 

Describe intervention: 

Intervention: NA 

RECRUITMENT: Physicians: (population-based, clinic-based, • Phase 1: 1,096 board certified physicians in general internal medicine, f

volunteer, other) practice, or obstetrics and gynecology were identified via professional and lo

• Phase 2: All physicians identified in Phase 1 were sent a survey 

• Phase 3: A portion of survey respondents (n= 81) were randomly select•	 Phase 4: Based on pilot study results, OB/GYN physicians were exclud

along with the physicians who responded to the pilot study 

•	 Phase 5: A second screening survey was sent to the remaining physicia

eligibility information 

• Phase 6 – The remaining physicians (207) were randomly assigned to o

physicians who asked them to participate in the study. 63 physicians agreed 

Patients: 

•	 Phase 1: Participating physicians identified female patients between the 

who had been seen by the physician in the past 3 months. (n = 3092) 

•	 Phase 2: Each patient received a letter from her physician that included 

study and a passive consent form. (remaining n = 2103) 

•	 Phase 3: Patients were contacted by telephone to determine final eligib

904 patients were surveyed. 

Note: While the initial numbers are large, the final sample sizes are much smaller. It is possible 

physicians are a highly select group and may not generally represent their peers. Althougused to account for the distribution of physicians based on certain demographic character
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY:	 Authors, ref ID: Fox et al.18 

Year of publication: 2009 Dates of data collection: not reported Trial name: Cancer screening adherence: Does physician-patient communication matter? account for other differences that might have influence. Also, physicians initially identified patients who would be contacted to participate in the study. There is no description of the 

other than a time period. In the end, there is no explanation of the distribution of patients aany specific physicians have more patients enrolled in the study than other physicians. A inclusion/exclusion criteria is not provided for either group. Statistical methods might limit effects, but the authors do not provide a clear explanation in the methodology, so it is diffiappropriately adjusted for these. There is one comment about using statistical methods to 

correlation. 

INCLUSION CRITERIA: Physicians: board certified in general internal medicine, family practice, or general practic

agreed to participate; met “other eligibility criteria.” (detailed eligibility criteria were not rep

Patients: female; between the ages of 50 – 80 years; been seen by a physician in the pasconsented to participate; met “other eligibility criteria,” completed a telephone survey. (detreported) 

EXCLUSION CRITERIA: Not described 

C-73 POPULATION CHARACTERISTICS:
 

Mean age & range (years): Sex (% female): Race: Other: 

Participating female patients 

Median age 64 years Female 100% Race/Ethnicity 

•	 White: n= 603 

(67%) 

•	 Asian/Pacific 

Islander: n= 41 (5%) 

•	 African American: 

n= 101 (11%) 

•	 Hispanic: n= 144 

(16%) 

• Other: n=8 (1%) 

SES 

•	 Annual household 

income >$15,000: n=599 (72%) 

•	 Education: high 

school diploma or more: n= 725 (80%) 

Health Insurance 

Participating Physician

Median age 49 years Male 91% Race/Ethnicity 

• White: n= 41 (65%) 

• Asian/Pacific Islander: n= 17 (2• African American: n= 2 (3%) • Hispanic: n= 1 (2%) • Other: n=2 (3%) 

Medical Specialty 

• Family Practice/Gen Med: n=35 

• General Internal Med: n=28 (44

Practice Setting 

•	 Private solo practice: n=35 (56%) 

•	 Private group practice: n= 27 (43%) •	 Public practice: n= 1 (2%) 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY:	 Authors, ref ID: Fox et al.18 

Year of publication: 2009 Dates of data collection: not reported Trial name: Cancer screening adherence: Does physician-patient communication matter? 

•	 HMO, IPA: n= 394 

(45%) 

•	 Other (PPO, Feefor-service, MediCal, 

MediCare, other): n= 453 (51%) 

•	 No insurance: n= 

38 (4%) 

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Attrition/Drop-out (not available for endpoint measurement): Adherence:
 Contamination: Response Rates (e.g. for surveys): 

Physicians After initially identifying 1,096 physicians, the researchers ended up with 63 physicians after the final phase of selection and recruitment. The article states that this represents a 44% recruitment rate after accounting for the multi-phase process. 

Patients After initially identifying 3,092 patients, the researchers ended up with 904 patients. The article states that this represents an estimated 51% recruitment rate across all phases. 

STATISTICAL ANALYSES: Describe: 

•	 Multilevel logistic regression using SAS GLIMMIX macro to model patie

and FOBT was used to account for the interclass correlation due to the hieraCMC data. 

• Sensitivity analyses performed to address issues of comparability for bo• Analyses controlled for a number of physician and patient characteristic

ASSESSMENT OF EXPOSURES AND See note above POTENTIAL CONFOUNDERS: OUTCOME ASSESSMENT: Outcome Measures: 

(Excluding mammography related outcomes) 

•	 % of patients reporting some discussion with their physician about FOBT for 

• Perceived level of physician’s enthusiasm • % of patients who received FOBT 

RESULTS: KQ2 - What factors influence the use of Outcomes: 

colorectal cancer screening? (Excluding mammography related outcomes)
 

• 42% of patients reported some discussion with their physician about FO

•	 20% of patients reported their physicians had a high level of enthusiasm abo

•	 29% of patients received FOBT (compared to 81% receiving a mammograp
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY:	 Authors, ref ID: Fox et al.18 

Year of publication: 2009 Dates of data collection: not reported Trial name: Cancer screening adherence: Does physician-patient communication matter? 

C-75
 

•	 Patients who perceived a low level of enthusiasm from provider were more l

than those who reported no discussion (AOR, 6.426; P < 0.0001); no significscreening for patients who perceived high enthusiasm. 

KQ3 - Which strategies are effective in increasing the appropriate use of colorectal cancer screening and followup? 

NA 

KQ4 - What are the current and NA projected capacities to deliver colorectal cancer screening and surveillance at the population level? KQ5 - What are the effective approaches for monitoring the use and quality of colorectal cancer screening? 

NA 

QUALITY RATING: Fair Quality Assessment-Internal Validity for Observational Studies 

Yes No Other (CD, NR, N

Were the groups similar at baseline regarding the most important prognostic indicators? NA 

Were the drop-out or response rates acceptable (≤ 20%)? [If between 20% and 60%, check See note above 

other and explain.] Were the differential drop-out or response rates acceptable (≤ 15%)? See note above 

Were intervention/exposure measures valid, reliable, and equally applied? CD Were the outcome assessors blinded to the intervention or exposure status of subjects? NA 

Were outcome measures valid, reliable, and equally applied? X Does the analysis control for baseline differences? X Were important potential confounding and modifying variables taken into account in the CD 

design and analysis (e.g., through matching, stratification, or statistical adjustment)? Were the statistical methods used to assess the abstracted outcomes appropriate? CD 

Quality Rating (Good, Fair, or Poor): Fair 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

C-76
 

STUDY:	 Authors, ref ID: Garman et al.19 

Year of publication: 2006 Dates of data collection: 2000-2001 Trial name: NR 

OBJECTIVE OR AIM: To examine the relationship between comorbid disease and performance of complete colo

colonoscopy or double contrast barium enema (DCBE) after positive screening FOBT in p

DESIGN: Setting: Single VA Center 

Study design: Retrospective medical record review Duration (mean follow-up): 12 months Overall study size (N enrolled/N analyzed): 266 

Sample size: 266 Describe intervention: RECRUITMENT: Clinic-based (VA) (population-based, clinic-based, volunteer, other) INCLUSION CRITERIA:	 ≥ 70 years, positive screening of FOBT, seen at Durham VA 

EXCLUSION CRITERIA: Patients were excluded if they had a FOBT performed for purposes other than screening o

year follow-up period. 

POPULATION CHARACTERISTICS: Mean age & range (years): Sex (% female): Mean Age: 75 (70 – 87); Sex (% female): 2%; White: 63%; Black: 24% Race:  White Cardiovascular disease: 14%; Depression: 8%; Pulmonary disease: 24% Black Other: Attrition/Drop-out (not available for 

endpoint measurement): NA Adherence:
 Contamination: Response Rates (e.g. for surveys): STATISTICAL ANALYSES: Describe: 

For analysis, a Charlson score of 3 was used as a cut-off point, given the known high morCharlson scores of 3 to 4.11; data on vision impairment, hearing impairment, hip fracture, collected as these have been included in prior assessments of function in geriatric patient

thrombosis and depression were also included, as they have been associated with worse 

CRC. 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY:	 Authors, ref ID: Garman et al.19 

Year of publication: 2006 Dates of data collection: 2000-2001 Trial name: NR 

C-77
 

ASSESSMENT OF EXPOSURES AND Comorbidity (based on Charlson Comorbidity index) POTENTIAL CONFOUNDERS: OUTCOME ASSESSMENT: Outcome Measures: RESULTS: KQ2 - What factors influence the use of	 Outcomes: 

colorectal cancer screening?	 193/266 (73%) referred for evaluation of positive FOBT 

109 (41%) underwent a colonoscopy or DCBE w/i 12 months of +FOBTNo relationship beof full colon exam No association found between Charlson score and referral to gastroenterology for follow-uNo association found between Charlson score and performance of complete colon exam No difference differences within comborbidty groups based on comorbidity Average time to full colon examination: 255 days 

KQ3 - Which strategies are effective in Outcomes: 

increasing the appropriate use of NA colorectal cancer screening and followup? KQ4 - What are the current and Outcomes: projected capacities to deliver NA colorectal cancer screening and
 surveillance at the population level? KQ5 - What are the effective approaches Outcomes: for monitoring the use and quality of NA colorectal cancer screening? QUALITY RATING: Fair 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

Quality Assessment-Internal Validity for Observational Studies 

Yes No Oth

Were the groups similar at baseline regarding the most important prognostic indicators? NA 

Were the drop-out or response rates acceptable (≤ 20%)? [If between 20% and 60%, check other and explain.] NA 

Were the differential drop-out or response rates acceptable (≤ 15%)? NA 

Were intervention/exposure measures valid, reliable, and equally applied? X Were the outcome assessors blinded to the intervention or exposure status of subjects? X Were outcome measures valid, reliable, and equally applied? X Does the analysis control for baseline differences? Were important potential confounding and modifying variables taken into account in the design and analysis (e.g., X 

through matching, stratification, or statistical adjustment)? Were the statistical methods used to assess the abstracted outcomes appropriate? X 

Quality Rating (Good, Fair, or Poor): Fair 

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Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

C-79
 

STUDY:	 Authors, ref ID: Gilbert, A., Kanarek, N.20 

Year of publication: 2005 Dates of data collection: 2002 Trial name: NA 

OBJECTIVE OR AIM: The primary objective of this study was to determine the predictors of colorectal cancer sc

DESIGN: Setting: Telephone survey 

Study design: Secondary data analysis of cohort survey study Duration (mean followup): One-time data collection Overall study size (N enrolled/N analyzed): 2,994 respondents analyzed 50-64 Years	 65+ Years 

Sample size: Sample size: 1,730 Sample size: 1,264 

Intervention: None, survey Intervention: None, survey 

Describe intervention: RECRUITMENT: Population-based; Maryland Cancer Survey
 

(population-based, clinic-based, volunteer, other) INCLUSION CRITERIA:	 English-speaking Marylanders age 40 and older residing in private residences 

EXCLUSION CRITERIA:	 ‘Don’t know’ or ‘refused’ responses for most covariates POPULATION CHARACTERISTICS: 50-64 Years 65+ Years 

Sex: 50.83% female Sex: 58.91% female 

Mean age & range (years): Sex (% female): Race: 

Race: 71.93% White, 22.32% Black, 5.75% Other 

Race: 80.15% White, 16,56% Black, 3.29% Other 

Other: 

All 

Attrition/Drop-out (not available for endpoint measurement): Adherence: 

Response rate was 38.4%; completion rate was 65.4% 

Contamination: Response Rates (e.g. for surveys): STATISTICAL ANALYSES: Describe: 

In initial multivariate analyses, there was a significant interaction for age and health insurawere considered in separate models (50–64 years and 65+ years). Unweighted multiple logistic regression analysis was performed by age category (50–64 y
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY:	 Authors, ref ID: Gilbert, A., Kanarek, N.20 

Year of publication: 2005 Dates of data collection: 2002 Trial name: NA FOBT within the past year, (2) sigmoidoscopy within the past 5 years, (3) colonoscopy wit(4) screening colonoscopy within the past 10 years. 

ASSESSMENT OF EXPOSURES AND NR POTENTIAL CONFOUNDERS: OUTCOME ASSESSMENT: Outcome Measures:
 

CRC screening outcomes were defined as (1) FOBT within the past year, (2) sigmoidoscoor (3) colonoscopy within the past 10 years. 

RESULTS: 

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KQ2 - What factors influence the use of colorectal cancer screening? 

Outcomes: Model results for persons aged 50–64 (FOBT)
 

The only significant predictor of FOBT use was clinician recommendation for the test (OR 50.29; P < 0.001). Sigmoidoscopy use was significantly lower among Blacks when compared to Whites (OR P = 0.026). Rural residents are less likely have had a timely sigmoidoscopy than urban re

CI: 0.42–0.88; P = 0.009). Persons in fair health are less likely to have had a timely sigmoexcellent, very good, or good health (OR = 0.49; 95% CI: 0.27–0.89; P = 0.019). Current shave had a timely sigmoidoscopy than non-smokers (OR = 0.39; 95% CI: 0.22–0.69; P = 

Reporting a family history of CRC significantly increases the odds of colonoscopy use (OR 3.68; P < 0.001). Independently, reporting having a clinician recommendation for the test raised the odds of 30:1 (OR = 31.76; 95% CI: 21.14–47.73; P < 0.001). 

Usual source of care was also important and positively associated with colonoscopy use (

5.27; P = 0.001). Women have decreased odds of screening colonoscopy use (OR = 0.66; 95% CI: 0.51–0

of Black race or Hispanic ethnicity have increased odds of screening colonoscopy use (O2.62; P < 0.001 and OR = 2.26; 95% CI: 1.05–4.88; P = 0.038, respectively). Those in an$25,000–49,999 and $75,000+ (compared to b$25,000) have increased odds of screening 1.66; 95% CI: 1.01–2.73; P = 0.05 and OR = 1.81; 95% CI: 1.09–3.01; P = 0.02, respectiv

improves the odds of screening colonoscopy (OR = 2.71; 95% CI: 1.93–3.81; P < 0.001). 

significantly raised the odds of screening colonoscopy (OR = 18.26; 95% CI: 11.27–29.57

of care was also positively associated with screening colonoscopy use (OR = 3.10; 95% CModel results for persons aged 65+
 Blacks were more likely to have had a timely FOBT than Whites (OR = 2.20; 95% CI: 1.38
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY:	 Authors, ref ID: Gilbert, A., Kanarek, N.20 

Year of publication: 2005 Dates of data collection: 2002 Trial name: NA 

C-81
 

with poor health status had almost 4 times the odds of FOBT use (OR = 3.75; 95% CI: 1.8

Those who reported a clinician recommendation for FOBT had over 26 times the odds of 19.25–37.11; P < 0.001). 

Having a usual source of care improves the odds of having a timely FOBT (OR = 3.28; 950.039). An annual income of $50,000–$74,999 compared to b$25,000 significantly improves the o(OR = 2.64; 95% CI: 1.30–5.37; P = 0.008). Clinician recommendation for the test improvemore than 11:1 (OR = 11.62; 95% CI: 5.04–26.76; P < 0.001). Current smokers have a borderline statistically significant decreased odds of colonoscopy 0.35–1.01; P = 0.055). Current drinkers also have a decreased odds of colonoscopy use (0.99; P = 0.045). Reporting having a family history of CRC improves the odds of colonosc1.48–3.38; P < 0.001). Reporting having a clinician recommendation for colonoscopy significantly increases the o20:1 (OR = 21.71, 95% CI: 14.87–31.72; P < 0.001). 

Family history of CRC increases the odds of screening colonoscopy use (OR = 2.60; 95% Clinician recommendation for colonoscopy significantly improves the odds of screening co95% CI: 5.82–12.99; P < 0.001). Ever had recommendation for FOBT, 50–64 years (N = 1730): Yes, 38.86 [1.37]; No, 61.1Ever had recommendation for FOBT, 65+ years (N = 1264): Yes, 44.64 [1.59]; No, 55.36 Ever had recommendation for sigmoidoscopy or colonoscopy, 50–64 years (N = 1730): Y[1.39] Ever had recommendation for sigmoidoscopy or colonoscopy, 65+ years (N = 1264): Yes[1.46] Those who ever had physician recommendation were more likely to have completed the FCI, 66.56-77.45); FS (AOR 17.41; 95% CI, 14.9-20.25); or colonoscopy (AOR 57.32; 95% 

KQ3 - Which strategies are effective in Outcomes: increasing the appropriate use of NA colorectal cancer screening and 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY: Authors, ref ID: Gilbert, A., Kanarek, N.20 

Year of publication: 2005 Dates of data collection: 2002 Trial name: NA 

followup? KQ4 - What are the current and Outcomes: projected capacities to deliver colorectal cancer screening and surveillance at the population level? 

NA 

KQ5 - What are the effective approaches for monitoring the use and quality of colorectal cancer screening? 

Outcomes: NA 

QUALITY RATING: Fair Quality Assessment-Internal Validity for Observational Studies 

Yes No O

Were the groups similar at baseline regarding the most important prognostic indicators? N

Were the drop-out or response rates acceptable (≤ 20%)? [If between 20% and 60%, check other and explain.] R

co

Were the differential drop-out or response rates acceptable (≤ 15%)? N

Were intervention/exposure measures valid, reliable, and equally applied? NWere the outcome assessors blinded to the intervention or exposure status of subjects? N

Were outcome measures valid, reliable, and equally applied? X Does the analysis control for baseline differences? X Were important potential confounding and modifying variables taken into account in the design and analysis (e.g., X through matching, stratification, or statistical adjustment)? Were the statistical methods used to assess the abstracted outcomes appropriate? X 

Quality Rating (Good, Fair, or Poor): Fair 

C-82
 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY:	 Authors, ref ID: Goel, S.M., Wee, C.C., McCarthy, E.P., Davis, R.B., Ngo-Metzger, Q., P

Year of publication: 2003 Dates of data collection: 1998 Trial name: NA 

OBJECTIVE OR AIM: To determine whether foreign birthplace explains some racial/ethnic disparities in cancer s

DESIGN: Setting: Home-based survey 

Study design: Cross-sectional study Duration (mean followup): No follow-up, one-time survey Overall study size (N enrolled/N analyzed): 32,440 Foreign-born	 U.S. born 

Sample size: Sample size: 4,963 Sample size: 27,441 

No intervention; survey No intervention; survey 

Describe intervention: RECRUITMENT: Population-based; National Health Interview Survey and Sample Adult and Sample Adult 

(population-based, clinic-based, volunteer, other) INCLUSION CRITERIA:	 Non-institutionalized, completed NHIS 

C-83 EXCLUSION CRITERIA:	 NR POPULATION CHARACTERISTICS:
 

Mean age & range (years): Sex (% female): Race: Other: 

Foreign-born Age: 25% <30, 26% 30-39, 20% 40­49, 13% 50-59, 8% 60-69, 6% 70­79, 3% 80+ Race: 28% White (non-Hispanic), 7% Black, 45% Hispanic, 29% AAPI Sex: 51% female 

U.S.-born Age: 22% <30, 21% 30-39, 21% 40­49, 14% 50-59, 10% 60-69, 8% 70­79, 4% 80+ Race: 82% White (non-Hispanic), 12% Black, 5% Hispanic, 1% AAPI Sex: 52% female 

Overall 

Attrition/Drop-out (not available for 74% response rate endpoint measurement): Adherence: Contamination: Response Rates (e.g. for surveys): STATISTICAL ANALYSES: Describe: independent variables of interest = race/ethnicity and foreign birth 

The authors conducted bivariable analyses comparing baseline characteristics between foindividuals, and compared screening rates across race/ethnicity and birthplace; used x2 svariables and a t-test for continuous variables; described the association between race/et

screening by fitting multivariable logistic regression models for each outcome of interest. 

ASSESSMENT OF EXPOSURES AND Authors adjusted for potential confounders previously described in the literature, including POTENTIAL CONFOUNDERS: characteristics (age, marital status, region of residence, education, annual household inco
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY:	 Authors, ref ID: Goel, S.M., Wee, C.C., McCarthy, E.P., Davis, R.B., Ngo-Metzger, Q., P

Year of publication: 2003 Dates of data collection: 1998 Trial name: NA (self-reported health status, smoking status, concurrent illnesses, BMI, and hospitalization

OUTCOME ASSESSMENT: Outcome Measures: 

The authors considered respondents screened if they reported FOBT in the previous yearconsidered screened if proctoscopy (sigmoidoscopy) was completed in the previous 5 yea

RESULTS: 

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KQ2 - What factors influence the use of colorectal cancer screening? 

Outcomes: •	 The authors found significant differences by race/ethnicity and by birthplace in screen

performed (P < .05). 

•	 Compared to white respondents, blacks, Hispanics, and AAPIs were generally less lik

sigmoidoscopies. 

•	 Similarly, compared with U.S.-born respondents, foreign-born respondents were also l

with all forms of cancer screening. 

•	 Black respondents were as likely to report FOBT and sigmoidoscopy as whites. Hispa

significantly less likely to report FOBT or sigmoidoscopy. AAPI respondents were less outcomes; however, the difference for FOBT was not statistically significant. 

•	 After adjusting for sociodemographic characteristics and illness burden, there were no 

cancer screening in U.S.-born nonwhite respondents compared with U.S.-born white re

•	 Foreign-born black respondents were significantly less likely to report FOBT; however

for access to care, this difference was attenuated and no longer significant (AOR, 0.51

•	 Foreign-born Hispanic respondents were significantly less likely to report FOBT and s

adjustment for access to care, differences were attenuated and were no longer statistic(AOR, 0.84; 95% CI, 0.60 to 1.18) or sigmoidoscopy (AOR, 0.80; 95% CI, 0.57 to 1.10)

•	 Foreign-born AAPI respondents were significantly less likely to report all screening pro

differences for FOBT (AOR, 0.73; CI, 0.45 to 1.19) and sigmoidoscopy (AOR, 0.74; 95% attenuated and no longer statistically significant. 

•	 Before adjustment, foreign-born Hispanic respondents were as likely to report FOBT, b

to report sigmoidoscopy compared with U.S.-born Hispanic respondents. Differences fosubstantially attenuated after adjustment and were no longer statistically significant. 

•	 Foreign-born AAPI respondents were also significantly less likely to report FOBT than 

respondents, before and after adjustment for sociodemographic characteristics and illnadjustment for access to care, the association between foreign birth and FOBT was suwas no longer statistically significant 

KQ3 - Which strategies are effective in Outcomes: NA increasing the appropriate use of colorectal cancer screening and followup? 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY:	 Authors, ref ID: Goel, S.M., Wee, C.C., McCarthy, E.P., Davis, R.B., Ngo-Metzger, Q., P

Year of publication: 2003 Dates of data collection: 1998 Trial name: NA 

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KQ4 - What are the current and Outcomes: NA projected capacities to deliver colorectal cancer screening and surveillance at the population level? KQ5 - What are the effective approaches Outcomes: NA for monitoring the use and quality of colorectal cancer screening? QUALITY RATING: Good 

Quality Assessment-Internal Validity for Observational Studies 

Yes No Other (C

Were the groups similar at baseline regarding the most important prognostic indicators? X There w

differensociodeU.S.- an

Were the drop-out or response rates acceptable (≤ 20%)? [If between 20% and 60%, check other and Combin

explain.] portions Were the differential drop-out or response rates acceptable (≤ 15%)?	 NR 

Were intervention/exposure measures valid, reliable, and equally applied? NA 

Were the outcome assessors blinded to the intervention or exposure status of subjects? NA 

Were outcome measures valid, reliable, and equally applied?	 X 

Does the analysis control for baseline differences? X 

Were important potential confounding and modifying variables taken into account in the design and analysis X (e.g., through matching, stratification, or statistical adjustment)? Were the statistical methods used to assess the abstracted outcomes appropriate? X 

Quality Rating (Good, Fair, or Poor): Good 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY:	 Authors, ref ID: Gupta S, et al.22 

Year of publication: 2009 Dates of data collection: 2002-2006 Trial name: Screening for Colorectal Cancer in a Safety Net Health Care System: Access 

Implications for Screening Policy 

OBJECTIVE OR AIM: To determine (a) the size of the potential screen-eligible population ages 50 – 75, (b) the 

years among individuals ages 54 – 75, and (c) the potential predictors of screening includinsurance status, frequency of out patient visits, and socioeconomic status. 

DESIGN: Setting: Electronic administrative records review of patients in a “safety-net” health care s

Hospital District John Peter Smith Hospital Health Network) Study design: cross-sectional (the authors describe it as a cohort study) Duration (mean followup): retrospectively reviewed 5 years of electronic administrative Overall study size (N enrolled/N analyzed): 

• Age-eligible individuals in 2006 = 31,166 

• Potential screen-eligible population in 2006 = 28,708 

• Number of patients analyzed = 20,416 

Sample size: N = 20,416 Describe intervention: Intervention: NA 

Reviewed administrative records for evidence of CRC screening between 2002 - 2006 

RECRUITMENT: Identified potentially eligible patients in the JPS health system database. (population-based, clinic-based, volunteer, other) 

C-86
 

INCLUSION CRITERIA:	 • Age 50 – 75 (ages 50 – 53 were excluded for the final analysis) 

• Alive as of 2006 

EXCLUSION CRITERIA:	 • History of inflammatory bowel disease, polyps, or colon cancer 

• Age 50 – 53 in 2006 

POPULATION CHARACTERISTICS:
 

Mean age & range (years): Sex (% female): Race: Other: 

•
 •
 

N = 20,416 Median age = 60 years Women = 59%
 White = 43.7%
 African-American = 27.7% Hispanic = 23.4% Other = 5.2% Primary Language spoken
 English = 82%
 Spanish = 12.5%
 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

C-87
 

STUDY:	 Authors, ref ID: Gupta S, et al.22 

Year of publication: 2009 Dates of data collection: 2002-2006 Trial name: Screening for Colorectal Cancer in a Safety Net Health Care System: Access 

Implications for Screening Policy Other = 5.6% 

Insurance status in 2006 None = 20.5%
 JPS Connection = 39.9% Medicare, Medicaid, private, or other = 39.6% Median household income = $35,419 

Attrition/Drop-out (not available for endpoint measurement): Adherence:
 Contamination: Response Rates (e.g. for surveys): STATISTICAL ANALYSES: Describe: 

•	 Descriptive statistics, including proportions with 95% CIs for estimates of rat

•	 Univariate and multivariate logistic regression to identify any association bet

of screening participation, and the primary outcome, the presence or absenc

completion. 

•	 Cochran-Armitage trend test used to investigate trend between screening an

coverage. 

ASSESSMENT OF EXPOSURES AND POTENTIAL CONFOUNDERS: 

Model included: age, sex, race/ethnicity, primary language, income, proportion of individucode), insurance, whether seen as an outpt in 2006 

OUTCOME ASSESSMENT: Outcome Measures: 

Size of potential screen-eligible population Rate of screening completion Predictors of screening completion Screening participation defined as: FOBT in 2005 or 2006/any BE, FS or colonscopy from 

RESULTS: KQ2 - What factors influence the use of	 Outcomes: 

colorectal cancer screening? •	 22% of those screen-eligible individuals aged 54 – 75 years had records of C

(defined as FOBT in 2005 or 2006, or any colonoscopy, flexible sigmoidoscobetween 2002 – 2006). 

•	 Independent predictors of screening completion used in multiple logistic reg

gender, race/ethnicity, primary language, measures of SES, insurance statu
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

C-88
 

STUDY:	 Authors, ref ID: Gupta S, et al.22 

Year of publication: 2009 Dates of data collection: 2002-2006 Trial name: Screening for Colorectal Cancer in a Safety Net Health Care System: Access 

Implications for Screening Policy 

more outpatient visits. The statistically significant associations were: o Female vs. male, OR = 1.25 (1.16 – 1.35) o Hispanic vs. White, OR = 1.2 (1.07 – 1.34) o Any health insurance vs. none, OR = 2.57 (2.23 – 2.98) o JPS insurance vs. none, OR = 2.55 (2.21 – 2.95) o Two or more outpatient visits in 2006, OR = 3.53 (3.15 – 3.97) 

KQ3 - Which strategies are effective in NA increasing the appropriate use of colorectal cancer screening and followup? KQ4 - What are the current and NA projected capacities to deliver colorectal cancer screening and surveillance at the population level? KQ5 - What are the effective approaches NA for monitoring the use and quality of colorectal cancer screening? QUALITY RATING: Fair 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

Quality Assessment-Internal Validity for Observational Studies 

Yes No Other (CD, NR, NA) 

Were the groups similar at baseline regarding the most NA – cross sectional retrospective records reviewimportant prognostic indicators? Were the drop-out or response rates acceptable (≤ 20%)? [If NA 

between 20% and 60%, check other and explain.] Were the differential drop-out or response rates acceptable (≤ NA 

15%)? Were intervention/exposure measures valid, reliable, and x equally applied? Were the outcome assessors blinded to the intervention or NR exposure status of subjects? Likely yes as this is administrative record review Were outcome measures valid, reliable, and equally applied? x Screening vs. diagnostic exams were not distingu

Used ICD9 codes to verify screening status, howhad access to records of procedures performed whealth records were not available for review. 

Does the analysis control for baseline differences? X The analysis adjusted for age category, race, pri

insurance status, presence of two or more out pahousehold income, and proportion living in poverincrements. 

C-89
 

Were important potential confounding and modifying Several factors were controlled for in the analysisvariables taken into account in the design and analysis (e.g., from unmeasured confounders such as comorbidthrough matching, stratification, or statistical adjustment)? Were the statistical methods used to assess the abstracted X outcomes appropriate? Quality Rating (Good, Fair, or Poor): Fair 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

C-90
 

STUDY:	 Authors, ref ID: Heo, M., et al.23 

Year of publication: 2004 Dates of data collection: 2001 Trial name: NA 

OBJECTIVE OR AIM: To estimate the association between body-mass index (BMI: kg/m2) and colorectal cance

US adults aged ≥ 50 years. 

DESIGN: Setting: United States 

Study design: Cross-sectional Duration (mean followup): One-time data collection, one year Overall study size (N enrolled/N analyzed): 84,284 All 

Sample size: Sample size: 84,284 Describe intervention: Intervention: None, survey (BRFFS) 

RECRUITMENT: Population-based (BRFFS) 

(population-based, clinic-based, volunteer, other) INCLUSION CRITERIA:	 Age 50+ 

EXCLUSION CRITERIA:	 Respondents (n = 250; .3%) with BMI's <18.5 ("underweight") were omitted from the analyPOPULATION CHARACTERISTICS:	 All Mean age & range (years): Mean age: 65 Sex (% female): Sex: 61.8% Female Race: Race: 82.3% white, 17.7% Non-white Other: Attrition/Drop-out (not available for NR 

endpoint measurement): Adherence:
 Contamination: Response Rates (e.g. for surveys): STATISTICAL ANALYSES: Describe: 

Multivariate logistic regression to estimate BMI screening associations by entering the and potential confounders into the model as either continuous (e.g., age [including poorder]) or dichotomous variables (e.g., health insurance). 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY: Authors, ref ID: Heo, M., et al.23 

Year of publication: 2004 Dates of data collection: 2001 Trial name: NA 

ASSESSMENT OF EXPOSURES AND POTENTIAL CONFOUNDERS: OUTCOME ASSESSMENT: RESULTS: 

To evaluate whether sex moderated the BMI-screening association, ran adjusted logiincluded BMI × sex interaction terms. Finally, because the authors observed a significthey then analyzed the data for men and women separately. 

This study has limitations including: the BRFSS, a telephone survey, is prone to measure

BRFSS is an observational study, the BMI-screening associations could be due to residuaconfounding from unmeasured variables; the cross-sectional design did not allow testing cpeople without telephones, approximately 3% of the US population, are not surveyed throOutcome Measures: BRFSS codes FOBT responses as: 'within past year', 'within past 2 years', 'within past 5 yago', 'don't know/not sure', or 'refused'. SIG is coded as: 'within past year', 'within past 2 y'within past 10 years', '10 or more years ago', 'don't know/not sure', or 'refused'. 

C-91
 

KQ2 - What factors influence the use of colorectal cancer screening? 

Outcomes: BMI was not associated with obtaining a FOBT (AOR's ranged from 0.90 to 0.98). Compared to normal weight adults, however, those in the overweight (OR = 1.15, 95%CI (1.21, 95%CI 1.09–1.35), II (1.17, 95%CI 1.04–1.44) and III (1.27, 95%CI 1.05–1.58) cate

have obtained a screening SIG within the previous 5 years (P's < 0.05). The interaction effect between sex and BMI categories on FOBT was not significant (χ2(4

However, the interaction effect between sex and BMI categories on SIG screening was sig<.0001). BMI was not associated with obtaining a FOBT for either sex (OR's ranged from Compared to normal weight men, men in the overweight (1.25, 95%CI 1.05–1.51) and obe1.03–1.75) categories were significantly more likely to have obtained a screening SIG. In (0.86 95%CI 0.78–0.94) and II (0.88 95%CI 0.79–0.99) women were less likely to have obcompared to normal weight women 

KQ3 - Which strategies are effective in Outcomes: NA increasing the appropriate use of colorectal cancer screening and followup? KQ4 - What are the current and Outcomes: NA projected capacities to deliver colorectal cancer screening and surveillance at the population level? KQ5 - What are the effective approaches Outcomes: NA for monitoring the use and quality of 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY: Authors, ref ID: Heo, M., et al.23 

Year of publication: 2004 Dates of data collection: 2001 Trial name: NA 

colorectal cancer screening? QUALITY RATING: Fair 

C-92
 

Quality Assessment-Internal Validity for Observational Studies 

Yes No Ot

Were the groups similar at baseline regarding the most important prognostic indicators? NA 

Were the drop-out or response rates acceptable (≤ 20%)? [If between 20% and 60%, check other and NR 

explain.] Were the differential drop-out or response rates acceptable (≤ 15%)? NA 

Were intervention/exposure measures valid, reliable, and equally applied? NA Were the outcome assessors blinded to the intervention or exposure status of subjects? NA 

Were outcome measures valid, reliable, and equally applied? X Does the analysis control for baseline differences? X Were important potential confounding and modifying variables taken into account in the design and analysis X 

(e.g., through matching, stratification, or statistical adjustment)? Were the statistical methods used to assess the abstracted outcomes appropriate? X 

Quality Rating (Good, Fair, or Poor): Fair 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

C-93
 

STUDY:	 Authors, ref ID: Honda, K., Kagawa-singer, M.24 

Year of publication: 2006 Dates of data collection: NR Trial name: NA 

OBJECTIVE OR AIM: The study aims are to (1) develop and test a model explaining how socioenvironmental an

related to colorectal cancer screening adherence, and (2) determine the relative importannorms) and attitudinal variables (perceived benefits and perceived behavioral control) for cancer screening adherence for this particular ethnic group. 

DESIGN: Setting: US 

Study design: Cross-sectional, retrospective (survey) Duration (mean followup): No follow-up Overall study size (N enrolled/N analyzed): 341 

Sample size: All 

Sample size: 341 

Describe intervention: 

Intervention: None; mailed survey in English and Japanese 

RECRUITMENT: Population-based 

(population-based, clinic-based, volunteer, other) INCLUSION CRITERIA:	 Japanese names (both first- and surname), age (over 50), and geographic location (NY, N

EXCLUSION CRITERIA:	 Did not provide demographic information POPULATION CHARACTERISTICS:	 All Mean age & range (years): Age range: 50-92 Sex (% female): Mean age: 64 Race: Sex: 63% female 

Ethnicity: Asian (Japanese American) 

Other: Attrition/Drop-out (not available for Response rate: 59% 

endpoint measurement): Adherence:
 Contamination: Response Rates (e.g. for surveys): 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY: Authors, ref ID: Honda, K., Kagawa-singer, M.24 

Year of publication: 2006 Dates of data collection: NR Trial name: NA 

STATISTICAL ANALYSES: Describe: 

The first step involved using confirmatory factor analysis (CFA) to test an overall meaThe second step involved using SEM to test a structural model. The squared multiple correlation (R2) value was reported for the endogeneous variab

of the model in explaining the variance observed in the sample’s screening behavior. Paths with nonsignificant t values were removed because no substantively meaningfuprovided for the parameter estimates 

ASSESSMENT OF EXPOSURES AND POTENTIAL CONFOUNDERS: 

NR 

OUTCOME ASSESSMENT: Outcome Measures: 

(1) never had any of three screening tests, (2) had at least one of three screening tests, bfrequency, and (3) had any of three screening tests with an appropriate frequency 

C-94 RESULTS: KQ2 - What factors influence the use of 

colorectal cancer screening? 

Outcomes: 

Results confirm the existence of a single latent construct underlying each of the meas

support, emotional friend support, and provider-patient communication in this populat

the latent variables were as follows: Provider-Patient Communication, 0.945; Emotion0.914; Emotional Support From Friends, 0.883. Five background variables (education, acculturation, marital status, frequency of contof contact with close friends) were not significant and were dropped from the “full” to t

The structural equations suggest that not all cognitive factors are significant in colore

adherence. Subjective norms among family and friends (γ = 0.20), perceived benefits 

subjective norms among providers and perceived behavioral control, had significant imcancer screening adherence. Among sociodemographics and social network variable

0.26), emotional friends support (γ = 0.15), income (γ = 0.14), and provider patient co

direct impacts on adherence, with the indirect effect of provider patient communicatiobenefits leading the total effect of 0.14. 

KQ3 - Which strategies are effective in Outcomes: NA increasing the appropriate use of colorectal cancer screening and followup? 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY: Authors, ref ID: Honda, K., Kagawa-singer, M.24 

Year of publication: 2006 Dates of data collection: NR Trial name: NA 

KQ4 - What are the current and Outcomes: NA projected capacities to deliver colorectal cancer screening and surveillance at the population level? KQ5 - What are the effective approaches for monitoring the use and quality of colorectal cancer screening? 

Outcomes: NA 

QUALITY RATING: Fair Quality Assessment-Internal Validity for Observational Studies 

Yes No Ot

Were the groups similar at baseline regarding the most important prognostic indicators? NA 

Were the drop-out or response rates acceptable (≤ 20%)? [If between 20% and 60%, check other and Re

explain.] on

acexon

Were the differential drop-out or response rates acceptable (≤ 15%)? NA Were intervention/exposure measures valid, reliable, and equally applied? NA Were the outcome assessors blinded to the intervention or exposure status of subjects? NA 

Were outcome measures valid, reliable, and equally applied? X Does the analysis control for baseline differences? X Were important potential confounding and modifying variables taken into account in the design and analysis X 

(e.g., through matching, stratification, or statistical adjustment)? Were the statistical methods used to assess the abstracted outcomes appropriate? X 

Quality Rating (Good, Fair, or Poor): Fair 

C-95
 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

C-96
 

STUDY:	 Authors, ref ID: Hudson, S.V., et al.25 

Year of publication: 2007 Dates of data collection: April 2003 through December 2004 Trial name: NA 

OBJECTIVE OR AIM: This study examines whether primary care practices that involve staff in general forms of 

higher CRC screening rates than practices that do not. 

DESIGN: Setting: Chart audit of practices 

Study design: Cross-sectional retrospective analysis Duration (mean followup): No followup, data collected over 20 months, 2003-2004 Overall study size (N enrolled/N analyzed): 22 practices, 795 patients 

Sample size: Sample size: 22 practices, 795 patients Describe intervention: Charts were audited to extract CRC screening RECRUITMENT: No individual recruitment of patients; Within each practice, 20 patients were randomly sele(population-based, clinic-based, patients. In cases where there were fewer than 20 patients in the practice with a particulavolunteer, other) patients with the diagnosis code were used. INCLUSION CRITERIA:	 Suburban practices were that had medical records with at least 10 years of data, 

EXCLUSION CRITERIA:	 If patients were deceased at the time of the audit, below age 18 or no longer a patient of t

POPULATION CHARACTERISTICS:	 Population 

Age range: 50-70 

Mean age & range (years): Mean age: 59.3 

Sex (% female): Sex: 45% female Race: Practices averaged 86% Caucasian patients Other: Attrition/Drop-out (not available for 

endpoint measurement): NA Adherence:
 Contamination: Response Rates (e.g. for surveys): STATISTICAL ANALYSES: Describe: 

Descriptive statistics were used to summarize rates of screening and teamwork indicators and practice-level socio-demographic information. Generalized estimating equations were used to examine the effects of the practice indicatcontrolling for additional practice-level covariates and patient-level covariates 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY:	 Authors, ref ID: Hudson, S.V., et al.25 

Year of publication: 2007 Dates of data collection: April 2003 through December 2004 Trial name: NA 

ASSESSMENT OF EXPOSURES AND Our sample was drawn mainly from a pool of patients with known chronic diseases (i.e., a

POTENTIAL CONFOUNDERS: disease, diabetes, hypertension). Though reflective of common diseases that affect many 

preventive colorectal cancer screening, this sample may over represent patients with chrorepresent others in the general patient population. 

OUTCOME ASSESSMENT: Outcome Measures: 

CRC screening, any procedure (URPSTF) 

RESULTS: KQ2 - What factors influence the use of colorectal cancer screening? 

Outcomes: Four of the 22 practices indicated that they used Health Risk Assessments (HRA’s) for dietobacco; however, the use of HRA’s was not significantly associated with CRC screening Practices using nursing staff for diet, physical activity and tobacco counseling had significrates than those not using nursing or health educator staff for such counseling (z = 7.30, P 

Practices using patient reminder systems had significantly higher CRC screening rates de

systems were not specifically targeting CRC screening (z = 4.96, P < 0.0001). CRC screening rates: Use of nonclinician staff for counseling: Yes: 54.1%; No: 27.2% [AOR, 2.96 (95% CI, 2.21Reminder systems: Yes: 39.9%; No: 19.6% [AOR, 2.57 (95% CI, 1.77-3.74)] 

C-97
 

KQ3 - Which strategies are effective in Outcomes: increasing the appropriate use of 31.3% of patients up to date for CRC screening colorectal cancer screening and
 followup?
 KQ4 - What are the current and Outcomes: NA projected capacities to deliver colorectal cancer screening and surveillance at the population level? KQ5 - What are the effective approaches Outcomes: NA for monitoring the use and quality of colorectal cancer screening? QUALITY RATING: Fair 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

Quality Assessment-Internal Validity for Observational Studies 

Yes No Ot

Were the groups similar at baseline regarding the most important prognostic indicators? X Were the drop-out or response rates acceptable (≤ 20%)? [If between 20% and 60%, check other and NA 

explain.] Were the differential drop-out or response rates acceptable (≤ 15%)? NA 

Were intervention/exposure measures valid, reliable, and equally applied? X Were the outcome assessors blinded to the intervention or exposure status of subjects? X Were outcome measures valid, reliable, and equally applied? X Does the analysis control for baseline differences? X Were important potential confounding and modifying variables taken into account in the design and analysis X 

(e.g., through matching, stratification, or statistical adjustment)? Were the statistical methods used to assess the abstracted outcomes appropriate? X Al

un

Quality Rating (Good, Fair, or Poor): Fair 

C-98
 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

C-99
 

STUDY:	 Authors, ref ID: Janz et al.26 

Year of publication: 2003 Date of data collection: 2001 Trial name: 

OBJECTIVE OR AIM: Assess attitudes and practices regarding CRC screening. 

DESIGN: Setting: Telephone survey of general population 

Study design: Cross-sectional, retrospective opulation-based random-digit-dialing telephDuration (mean followup): None Overall study size (N enrolled/N analyzed): 355 

Sample size: Population Describe intervention: Sample size: 355 RECRUITMENT: Population-based; purchased random phone numbers and addresses (population-based, clinic-based, volunteer, other) INCLUSION CRITERIA:	 Age 50-79, residents of Genessee County, Michigan, household telephone number 

EXCLUSION CRITERIA: Prior history of colorectal cancer, colorectal surgery to remove polyp, inflammatory bowel 

adenomatous polyposis. 

POPULATION CHARACTERISTICS:	 Population 

Mean age & range (years): Age range: 50-79 Sex (% female): Sex: 55% female Race: Race: 48% Black; 52% White Other: 

Population 

Attrition/Drop-out (not available for endpoint measurement): Response rate = 69% Adherence: Contamination: Response Rates (e.g. for surveys): STATISTICAL ANALYSES: Describe: 

Demographic variables and variables measuring respondents’ familiarity with or use of scanalyzed using two-way contingency tables with accompanying x2 statistics which test the difference among race-gender groups. Logistic regression models were used to test whether dimensions represented in the Heasignificantly related to CRC screening status while controlling for relevant sociodemograp

ASSESSMENT OF EXPOSURES AND Across all three screening procedures, two consistent barriers were the personal beliefs th

POTENTIAL CONFOUNDERS: needed” or would be “embarrassing.” Other barriers were unique to a specific screening te
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY:	 Authors, ref ID: Janz et al.26 

Year of publication: 2003 Date of data collection: 2001 Trial name: reported that a barrier to FOBT was “not knowing how to perform the self-test,” and 11% r“bleeding or tearing” with colonoscopy. About 30% of participants reported that pain was a sigmoidoscopy and colonoscopy. Moreover, a cluster of emotional reactions to these tests barriers to action. For each test, significant numbers of respondents indicated “anxiety abo“fear of the results.” Ten percent of the respondents considered cost a barrier to flexible sdropped to 7% for colonoscopy. 

OUTCOME ASSESSMENT: Outcome Measures: 

Attitudes and practices related to CRC screening. 

RESULTS: 

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KQ2 - What factors influence the use of colorectal cancer screening? 

Outcomes: 

•	 Significantly high percentages of white respondents than black respondents were 

precedures for both endoscopic procedures (P < 0.05). 

•	 There was considerable attenuation as one move from knowledge of any screenin

the particular screening test. There was further reduction between having ever beadherence to recommended screening guidelines. 

•	 Adherence to the recommended screening interval was lowest in black females fo

21.8% for FOBT, 20.5% for flexible sigmoidoscopy, and 12.8% for colonoscopy. 

•	 Black males reported greater rates of prior and current screening than white males 

sigmoidoscopy and colonoscopy. 

•	 Males reported high screening percentages. 

•	 The only significant differences among gender and race subgroups were observed 

flexible sigmoidoscopy” (P = 0.011); “having heard of a colonoscopy” (P = 0.001); flexible sigmoidoscopy” (P = 0.037) 

•	 Looking at adherence according to American Cancer Society, the following percen

adherent: black males (37.8%); white males (24.8%); black females (19.2%); and 

•	 Between 54 and 65% of respondents indicated that their physician had recommen

of those subjects reported having had the test. (P = NR, OR = NR) 

•	 There were no significant differences at the P < 0.05 level between race and gend

percentage reporting a physician recommendation or the percentage screened amrecommendation. 

•	 Increasing age was significantly associated with a greater likelihood of obtaining a 

colonoscopy. 

•	 A family history of colorectal cancer was significantly associated with an increased 

colonoscopy in the recommended interval (OR= 3.02, 95% CI =1.29, 7.09). 

•	 Respondents considering themselves at higher risk for colorectal cancer compare

were 1.24 times (95% CI 1.01, 1.52) more likely to have had a flexible sigmoidoscinterval. 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY: Authors, ref ID: Janz et al.26 

Year of publication: 2003 Date of data collection: 2001 Trial name: 

KQ3 - Which strategies are effective in increasing the appropriate use of colorectal cancer screening and followup? 

NA 

KQ4 - What are the current and projected capacities to deliver colorectal cancer screening and surveillance at the population level? 

NA 

KQ5 - What are the effective approaches for monitoring the use and quality of colorectal cancer screening? 

NA 

QUALITY RATING: Fair Quality Assessment-Internal Validity for Observational Studies 

Yes No Other (CD, NR, N

Were the groups similar at baseline regarding the most important prognostic indicators? 

NA 

Were the drop-out or response rates acceptable (≤ 20%)? [If between 20% and 60%, check other and explain.] 

Response rate wa

Were the differential drop-out or response rates acceptable (≤ 15%)? NA 

Were intervention/exposure measures valid, reliable, and equally applied? X Were the outcome assessors blinded to the intervention or exposure status of subjects? 

X People doing inte

factors and outcom

Were outcome measures valid, reliable, and equally applied? NA Does the analysis control for baseline differences? X Were important potential confounding and modifying variables taken into account in the design and analysis (e.g., through matching, stratification, or statistical adjustment)? 

X 

Were the statistical methods used to assess the abstracted outcomes appropriate? X 

Quality Rating (Good, Fair, or Poor): Fair 

C-101
 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY:	 Authors, ref ID: Jerant, AF, et al.27 

Year of publication: 2008 Dates of data collection: 1999-2005 Trial name: NR 

OBJECTIVE OR AIM: To examine factors associated with disparities in CRC screening between whites and Hisp

subgroups. 

DESIGN: Setting: US 

Study design: Cross-sectional, secondary data analysis of survey data Duration (mean followup): One-time data collection each year, 1999-2005 Overall study size (N enrolled/N analyzed): 22,419 All 

Sample size: Sample size: 22,419 (18,733 White, 2,779 Mexican, 336 Cuban, 376 Puerto Rican, 195 DDescribe intervention: Intervention: None; used MEPS data RECRUITMENT: Population-based (population-based, clinic-based, volunteer, other) 

C-102 INCLUSION CRITERIA: Respondents aged >50 years self-identifying as non-Hispanic white or Hispanic 
 

EXCLUSION CRITERIA: Individuals not of Mexican, Cuban, Puerto Rican, or Dominican origin 

POPULATION CHARACTERISTICS: White Mexican Cuban Puerto Rican 

Age: 23.1% 50-54, Age: 29.1% 50-54, 22.3% 50-54, 13.7% 23.9% 50-54, 

Mean age & range (years): 19.4% 55-59, 14.9% 21.7% 55-59, 55-59, 10.4% 60-64, 25.3% 55-59, 

Sex (% female): Race: 

60-64, 22.6% 65-74, 20% 75+ 

13.5% 60-64, 22.1% 65-74, 

28.5% 65-74, 25.2% 75+ 

22.6% 60-64, 18.9% 65-74, 9.2

Sex: 53.8% female 13.6% 75+ Sex: 52% female 75+ 

Other: Sex: 53.8% female Sex: 60.4% fema

All 

Attrition/Drop-out (not available for endpoint measurement): Adherence: 

Response rate about 65% 

Contamination: Response Rates (e.g. for surveys): STATISTICAL ANALYSES: Describe: 

•	 Analyses incorporated the longitudinal strata and primary sampling units and we

appropriate standard errors and estimates representative of the U.S. civilian, nonpopulation. (DR note: this was cross sectional study.) 

•	 Four main models were constructed to determine the relationship between CRC 

national origin subgroup using a series of logistic regression analyses with CRC 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY:	 Authors, ref ID: Jerant, AF, et al.27 

Year of publication: 2008 Dates of data collection: 1999-2005 Trial name: NR 

dependent variable in the models. 

•	 The modeling sequence was designed to adjust first for relatively fixed demograp

basic socioeconomic factors common to all persons, then access factors commofinally, language, a factor of specific relevance to Hispanics in this analysis. 

ASSESSMENT OF EXPOSURES AND Nonetheless, the data regarding geographic region by ethnicity presented in Table 1 sugg

POTENTIAL CONFOUNDERS: confounding even by broad geographic region, and our models adjusted for such confounOUTCOME ASSESSMENT: Outcome Measures: 

Dependent variable: self-report of up to date CRC screening, defined as fecal occult and/or lower endoscopy at any time 

RESULTS: KQ2 - What factors influence the use of colorectal cancer screening? 

C-103
 

Outcomes: 

•	 Total unadjusted screening rates: Non-Hispanic whites: 55.9%, Mexican: 35.2%, 

Rican: 45.7%, Dominican: 28.5% 

•	 Adjusted for age, gender, region and year: Mexican: (AOR, 0.46; 95% CI, 0.40-0

0.65; 95% CI, 0.47-0.91), Dominican: (AOR, 0.30; 95% CI, 0.19-0.45) 

•	 Adjusted for above plus income and education: Mexican: (AOR, 0.70; 95% CI, 0.

(AOR, 0.44; 95% CI, 0.28-0.69) 

•	 Adjusted for above plus insurance, usual source of care, health status: Mexican: 

0.91), Dominican: (AOR, 0.54; 95% CI, 0.32-0.91) 

•	 Compared with non-Hispanic whites, all Hispanic national origin subgroups exce

were significantly less likely to report up to date CRC screening, after adjustmenyear (Mexican: OR .46, 95% CI: .40, .53, P = 0.00; Puerto Rican: OR. .65, 95% C

Dominican: OR .30, 95% CI .19, .45, P = 0.00) 

•	 With additional adjustment for socioeconomics, the effect for people of Puerto Ri

significant (Mexican: OR .70, 95% CI .60, .81, P = 0.00; Dominican: OR .44, 95% 

•	 With further adjustment for access (insurance status, and availability of a usual s

further non-significant attenuation of disparities (Mexican: OR .79, 95% CI .69, .9

OR .54, 95% CI .32, .91, P = 0.02). 

•	 The final model, including language revealed further attenuation of the disparity b

whites and Hispanics (with no remaining statistically significant disparity), while phigher adjusted screening rates (Cuban: OR 1.57, 95% CI 1.15, 2.14, P = 0.01). 

KQ3 - Which strategies are effective in NA increasing the appropriate use of colorectal cancer screening and followup? KQ4 - What are the current and	 NA 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY: Authors, ref ID: Jerant, AF, et al.27 

Year of publication: 2008 Dates of data collection: 1999-2005 Trial name: NR 

projected capacities to deliver colorectal cancer screening and surveillance at the population level? KQ5 - What are the effective approaches for monitoring the use and quality of colorectal cancer screening? 

NA 

QUALITY RATING: Good Quality Assessment-Internal Validity for Observational Studies 

Yes No Other (CD, NR, N

Were the groups similar at baseline regarding the most important prognostic Population demogindicators? country of origin. Were the drop-out or response rates acceptable (≤ 20%)? [If between 20% and Response rate ab

60%, check other and explain.] Were the differential drop-out or response rates acceptable (≤ 15%)? NA 

Were intervention/exposure measures valid, reliable, and equally applied? NA Were the outcome assessors blinded to the intervention or exposure status of NA 

subjects? Were outcome measures valid, reliable, and equally applied? X Does the analysis control for baseline differences? X Were important potential confounding and modifying variables taken into account in X the design and analysis (e.g., through matching, stratification, or statistical adjustment)? Were the statistical methods used to assess the abstracted outcomes appropriate? X 

Quality Rating (Good, Fair, or Poor): Good 

C-104
 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

C-105
 

STUDY:	 Authors, ref ID: Jerant, A.F., et al.28 

Year of publication: 2008 Dates of data collection: 2001-2005 Trial name: NR 

OBJECTIVE OR AIM: To address these limitations in the literature, the authors examined the correlates of CRC 

major US racial/ethnic categories (non-Hispanic white, Asian, black, and Hispanic individuthe 2001-2005 Medical Expenditure Panel Survey (MEPS) and the 2000-2004 NHIS. 

DESIGN: Setting: USA; Medical Expenditure Panel Survey and the National Health Interview Surve

Study design: Cross-sectional) Duration (mean followup): One-time data analysis Overall study size (N enrolled/N analyzed): 22973/21,433 All 

Sample size: Sample size: 22,973 (no missing data = 21,433) Describe intervention: Intervention: None; Medical Expenditure Panel Survey and the National Health Interview S

RECRUITMENT: Population-based survey
 

(population-based, clinic-based, volunteer, other) INCLUSION CRITERIA:	 Civilian, noninstitutionalized population, age 50+ 

EXCLUSION CRITERIA:	 NR POPULATION CHARACTERISTICS:	 All 

Age: 23.6% 50-54, 19.7% 55-59, 

Mean age & range (years): 14.8% 60-64, 22.2%, 65-74, 19.6% Sex (% female): 75+ Race: Sex: 54.1% female 

Race: 68% White (non-Hispanic), 

Other: 3.4 Asian, 13.7% Black, 14.9% 

Hispanic 

Attrition/Drop-out (not available for MEPS point-in-time response rates for the 5 panels of public use data that the authors use

endpoint measurement): 70.5%; 2001, 71.4%; 2002, 69.2%; 2003, 68.9%; 2004, 68.2%; and 2005, 66.5%.
 Adherence:
 Contamination: Response Rates (e.g. for surveys): STATISTICAL ANALYSES: Describe: 

They constructed 3 sets of analyses with 4 sequential logistic regression models to determ
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY:	 Authors, ref ID: Jerant, A.F., et al.28 

Year of publication: 2008 Dates of data collection: 2001-2005 Trial name: NR between CRC screening and race/ethnicity (non-Hispanic white, Asian, black, and Hispanthe dependent variable in all the models. Model 1: adjusted only for basic demographics (age, sex, MSA residence, and region of UModel 2: adjusted for SES (annual income and educ level) Model 3: included also access to care (insurance, USOC) and self-rated health Model 4: incl also language spoken at home and nativity 

ASSESSMENT OF EXPOSURES AND Modeling included potential confounders noted above POTENTIAL CONFOUNDERS: OUTCOME ASSESSMENT: Outcome Measures: 

CRC screening; respondents were considered to be up-to-date for screening if they repor

years or endoscopic testing at any time Combined, FOBT alone, endoscopy alone 

C-106 RESULTS:
 

KQ2 - What factors influence the use of colorectal cancer screening? 

Outcomes: After adjustment for age, sex, MSA residence, region, and year, (MODEL 1) compared wiminorities, and especially Asians and Hispanics, were significantly less likely to report up-With additional socioeconomic adjustment (MODEL 2), the disparities in CRC screening wHispanics and blacks (and, for blacks, eliminated for FOBT) relative to non-Hispanic whitechange in Asian/non-Hispanic white disparities. The gradient in screening was steepest for educational level, with the most educated grouhaving adjusted odds ratios of greater than 2.00 relative to the least educated group (less 

Adjustment for access and self-rated health (MODEL 3) further attenuated Hispanic/non-Hdisparities but had little effect on Asian/non-Hispanic white disparities. For FOBT, blacks being up-to-date than were non-Hispanic whites. Those with worse self-rated health, availability of some insurance, and a usual source of creport screening. With the inclusion of language and nativity MODEL 4), Hispanic/non-Hispanic white dispathat they were no longer statistically significant, whereas Asian/non-Hispanic white disparremained significant. Speaking English at home and being born in the continental United States were associatescreening. Analyses that included language and nativity separately suggested that langua
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY:	 Authors, ref ID: Jerant, A.F., et al.28 

Year of publication: 2008 Dates of data collection: 2001-2005 Trial name: NR 

C-107
 

was the main driver of the attenuation in disparities. Absolute rates for screening among blacks were 25.5% for FOBT; 38.3% for endoscopy; acombined tests; among non-Hispanic whites, rates were 25.8%, 49.0, and 57.2%, respectInitial analysis (adjusted for demographics) showed blacks to be significantly less likely thhave CRC tests (unadjusted OR 0.72; 95% CI, 0.65-0.80) Further adjustment to the model (i.e., when foreign birth, language spoken at home are taeliminated these differences. Unadjusted screening rates: Asians: 14.8% FOBT; 27.5% endoscopy; 33.8% combined FNon-Hispanic whites: 25.8% FOBT; 49.0% endoscopy; 57.2% combined FOBT and endosAdjusted for age, gender, region: AOR, 0.41; 95% CI, 0.33-0.50 Adjusted for above plus income and education: AOR, 0.42; 95% CI, 0.34-0.52 

Adjusted for above plus insurance, usual source of care, health status: AOR, 0.44; 95% C

Adjusted for above plus language spoken at home, nativity: AOR, 0.63; 95% CI, 0.49-0.8

Respondents who reported speaking English at home were more likely to report being screnot (AOR, 1.84; 95% CI, 1.52-1.33 for combined screening with FOBT or endoscopy) 

Those born in the US were also more likely to be screened than those who were not (AOR

KQ3 - Which strategies are effective in Outcomes: NA increasing the appropriate use of colorectal cancer screening and followup? KQ4 - What are the current and Outcomes: NA projected capacities to deliver colorectal cancer screening and surveillance at the population level? KQ5 - What are the effective approaches Outcomes: NA for monitoring the use and quality of colorectal cancer screening? QUALITY RATING:	 Good 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

Quality Assessment-Internal Validity for Observational Studies 

Yes No Other (CD, NR, 

C-108
 

Were the groups similar at baseline regarding the most important prognostic indicators? Were the drop-out or response rates acceptable (≤ 20%)? [If between 20% MEPS point-in-t

and 60%, check other and explain.] for the 5 panels 

that we used we70.5%; 2001, 712003, 68.9%; 202005, 66.5%. 

Were the differential drop-out or response rates acceptable (≤ 15%)? X 

Were intervention/exposure measures valid, reliable, and equally applied? NA Were the outcome assessors blinded to the intervention or exposure status NA of subjects? Were outcome measures valid, reliable, and equally applied? X Does the analysis control for baseline differences? X Were important potential confounding and modifying variables taken into X account in the design and analysis (e.g., through matching, stratification, or statistical adjustment)? Were the statistical methods used to assess the abstracted outcomes X appropriate? Quality Rating (Good, Fair, or Poor): Good Reviewer #1 initials: BLM Reviewer #2 initials: DR Comments (explain poor quality ratings): 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

C-109
 

STUDY:	 Authors, ref ID: Katz, M., et al.29 

Year of publication: 2004 Dates of data collection: Focus group: 1998; Survey October 1998 to October 1999 Trial name: WATCH (Wellness for African Americans Through Churches) Project 

OBJECTIVE OR AIM: The authors sought to determine the relationship between the general quality of self-rated 

communication and the completion of CRC screening. 

DESIGN: Setting: Rural churches in North Carolina 

Study design: Cohort survey study Duration (mean followup): One-year data collection Overall study size (N enrolled/N analyzed): 397 analyzed All 

Sample size: Sample size: 397 

Intervention: None, focus group 

Describe intervention: and telephone survey of church 

members 

RECRUITMENT: Church-based
 

(population-based, clinic-based, volunteer, other) INCLUSION CRITERIA:	 Age 50+ 

EXCLUSION CRITERIA:	 Deceased, no longer living in the state, medically incapable, phone number no longer wor

POPULATION CHARACTERISTICS:	 All 

Sex: 73,8% female 

Mean age & range (years): Race: 98% African American Sex (% female): Mean age: 63 years Race: Other: 

All 

Attrition/Drop-out (not available for Adjusted response rate: 66% endpoint measurement): Adherence: Contamination: Response Rates (e.g. for surveys): STATISTICAL ANALYSES: Describe: 

Analyses of data from this study included factor analysis, analysis of variance, and logistic 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY:	 Authors, ref ID: Katz, M., et al.29 

Year of publication: 2004 Dates of data collection: Focus group: 1998; Survey October 1998 to October 1999 Trial name: WATCH (Wellness for African Americans Through Churches) Project 

C-110
 

Logistic regression analyses were performed to evaluate whether the level of perceived pcommunication was significantly related to CRC screening behavior in this population. Sowere identified as potential covariates if there was plausible theoretical or empirical evidenbe associated with the communication variable or with CRC screening. Only the sex of the participant, receiving healthcare at a doctor's office versus a clinic/emeknowledge of CRC risk were significantly associated with communication and only these tentered into the initial logistic model. 

ASSESSMENT OF EXPOSURES AND Participants were categorized as having "good" communication if they perceived receiving 

POTENTIAL CONFOUNDERS: their provider, being involved in medical decisions, and thinking that their provider underst

almost all the time or always. This was self-rated 

OUTCOME ASSESSMENT: Outcome Measures:
 

Participants were considered to have been screened within the recommended time period the preceding year, and sigmoidscopy within the preceding 5 years. 

RESULTS: KQ2 - What factors influence the use of	 Outcomes: 

colorectal cancer screening?	 After adjustment for the sex of the participant and source of healthcare, quality of commun

as rated by patient) remained significantly associated with completion of a CRC test (OR= P = 0.002). CRC screening results by communication: 

CRC screening in recommended P value time (%) 

Poor and fair communication 

Inadequate knowledge (n=40) 15.0 0.654 

 Adequate knowledge (n=54) 18.5 Good communication 

 Inadequate knowledge (n=124) 27.4 0.012  Adequate knowledge (n=173) 41.6 

KQ3 - Which strategies are effective in Outcomes: NA increasing the appropriate use of colorectal cancer screening and followup? 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY:	 Authors, ref ID: Katz, M., et al.29 

Year of publication: 2004 Dates of data collection: Focus group: 1998; Survey October 1998 to October 1999 Trial name: WATCH (Wellness for African Americans Through Churches) Project 

C-111
 

KQ4 - What are the current and Outcomes: NA projected capacities to deliver colorectal cancer screening and surveillance at the population level? KQ5 - What are the effective approaches Outcomes: NA for monitoring the use and quality of colorectal cancer screening? QUALITY RATING: Fair Quality Assessment-Internal Validity for Observational Studies 

Yes No Other (CD, NR, 

Were the groups similar at baseline regarding the most important prognostic NA 

indicators? Were the drop-out or response rates acceptable (≤ 20%)? [If between 20% Adjusted responand 60%, check other and explain.] Were the differential drop-out or response rates acceptable (≤ 15%)? NA 

Were intervention/exposure measures valid, reliable, and equally applied?	 NA 

Were the outcome assessors blinded to the intervention or exposure status NA of subjects? Were outcome measures valid, reliable, and equally applied?	 X 

Does the analysis control for baseline differences? X 

Were important potential confounding and modifying variables taken into X 

account in the design and analysis (e.g., through matching, stratification, or statistical adjustment)? Were the statistical methods used to assess the abstracted outcomes X appropriate? Quality Rating (Good, Fair, or Poor): Fair Reviewer #1 initials: BLM Reviewer #2 initials: MJG Comments (explain poor quality ratings): 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

C-112
 

STUDY:	 Authors, ref ID: Klabunde et al.30 

Year of publication: 2005 Dates of data collection: 1999-2000 Trial name: NA 

OBJECTIVE OR AIM: The authors sought to compare barriers to CRC screening reported by primary care physi

average-risk adults, and to examine characteristics of average-risk adults who identified larecommendation as a major barrier to CRC screening. 

DESIGN: Setting: Surveys of doctors (PCPs) and patients (from NHIS) 

Study design: Secondary data analysis, comparison study, cross-sectional Duration (mean follow-up): No follow-up, data collected 1999-2000 Overall study size (N enrolled/N analyzed): 1,235 PCPs, 6,497 adults 

Sample size: Primary Care Physicians (PCPs) Patients 

Sample size: 1,235 Sample size: 6,497 

Describe intervention: Intervention: Survey of Colorectal Cancer Intervention: National Health Interview Surve

Screening Practices (SCCSP) (NHIS) 

RECRUITMENT: Population-based; Survey of Colorectal Cancer Screening Practices (SCCSP) and Nation(population-based, clinic-based, (NHIS) volunteer, other) INCLUSION CRITERIA: NHIS respondents age 50+ at average risk for CRC; SCCSP: PCPs (family/general practi

obstetrician/gynecologists) 

EXCLUSION CRITERIA: Respondents who reported having a personal or family history (ie, one or more first-degrePOPULATION CHARACTERISTICS: 

NR 

Mean age & range (years): Sex (% female): Race: Other: Attrition/Drop-out (not available for endpoint measurement): Adherence: Contamination: Response Rates (e.g. for surveys): 

All 2 surveys with response rates exceeding 70% 

STATISTICAL ANALYSES: Describe: 

They used contingency tables with x2 tests to assess sociodemographic and health care a

with average-risk adults not current with CRC screening and reporting lack of physician remain reason. They entered variables that showed a statistically significant association in bivariate analy
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY:	 Authors, ref ID: Klabunde et al.30 

Year of publication: 2005 Dates of data collection: 1999-2000 Trial name: NA into 2 logistic regression models to further assess potential predictors in multivariate analy

ASSESSMENT OF EXPOSURES AND NR POTENTIAL CONFOUNDERS: OUTCOME ASSESSMENT: Outcome Measures:
 

Measured barriers to CRC screening identified by PCPs and average-risk adults who werscreening. 

RESULTS: 

C-113
 

KQ2 - What factors influence the use of colorectal cancer screening? 

Outcomes: PCPs more often identified patient-related (80%) than health care system-related (68%) fa

Similarly, average-risk adults who were not current with CRC screening more often identifthan system-related (22%) barriers as the main reason they were not current with testing, colorectal endoscopy. Although a majority of PCPs (56%) identified patient embarrassment or anxiety about CRmajor barrier, #1% of adults indicated this as their main reason for not being current with sOf the system-related barriers, PCPs more often identified cost/lack of insurance coverag

than did adults (>1%). 37% of PCPs identified failure of PCPs to actively recommend CRC screening to their pat

compared to approximately 20% of adults. PCPs; N, 1235; %, 67.6; 95% CI, 65.0–70.2; Adults Aged 50 or Older Who had not Been 

FOBT: N, 6497; %, 21.6; 95% CI, 20.2–23.0 or CRE: N, 6497; %, 22.2; 95% CI, 20.9–23.6

failure of PCPs to actively recommend CRC screening to their patients as a major barrier, approximately 20% of adults. 

KQ3 - Which strategies are effective in Outcomes: 

increasing the appropriate use of NA colorectal cancer screening and followup?
 KQ4 - What are the current and Outcomes: projected capacities to deliver NA colorectal cancer screening and
 surveillance at the population level?
 KQ5 - What are the effective approaches Outcomes: for monitoring the use and quality of NA colorectal cancer screening? 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY:	 Authors, ref ID: Klabunde et al.30 

Year of publication: 2005 Dates of data collection: 1999-2000 Trial name: NA 

C-114
 

QUALITY RATING: Fair Quality Assessment-Internal Validity for Observational Studies 

Yes No Other (CD, NR, 

Were the groups similar at baseline regarding the most important prognostic N/A indicators? Were the drop-out or response rates acceptable (≤ 20%)? [If between 20% 2 surveys with rand 60%, check other and explain.] exceeding 70% Were the differential drop-out or response rates acceptable (≤ 15%)? N/A Were intervention/exposure measures valid, reliable, and equally applied? N/A Were the outcome assessors blinded to the intervention or exposure status N/A of subjects? Were outcome measures valid, reliable, and equally applied? X Does the analysis control for baseline differences? X Were important potential confounding and modifying variables taken into X account in the design and analysis (e.g., through matching, stratification, or statistical adjustment)? Were the statistical methods used to assess the abstracted outcomes X appropriate? Quality Rating (Good, Fair, or Poor): Fair 

Reviewer #1 initials: BLM Reviewer #2 initials: Comments (explain poor quality ratings):
 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

C-115
 

STUDY:	 Authors, ref ID: Koroukian, S.M., et al.31 

Year of publication: 2005 Dates of data collection: 1998-1999 Trial name: NA 

OBJECTIVE OR AIM: The authors sought to study colorectal cancer screening among Medicare FFS beneficiar

Medicare managed care activity (MCA). 

DESIGN: Setting: US 

Study design: Cross-sectional study Duration (mean followup): No follow-up, data from 1998-19999 Overall study size (N enrolled/N analyzed): 23 million (2,655 counties) Low MCA	 Moderate MCA High MCA 

Sample size: Sample size: 2027 counties Sample size: 449 counties Sample si

No intervention No intervention No interve

Describe intervention: RECRUITMENT: Population-based; 1999 population-based Outpatient Standard Analytic File (SAF) and Ph

(population-based, clinic-based, (SAF) file, 1999 Denominator file, and 1998 ARF volunteer, other) INCLUSION CRITERIA: Medicare beneficiaries age 65+, counties in contiguous states and Hawaii with more than 

those in which total enrollment in Medicare FFS exceeded 10,000 months 

EXCLUSION CRITERIA:	 8 counties without gastroenterologists or primary care physicians, as well as 36 unique ar

Medicare files but not in the Area Resource File (ARF); claims that carried—at the procedlevel—additional diagnosis codes indicating symptoms (eg, abdominal distension, or anemsuch as Crohn disease, for which surveillance was indicated; barium enema 

POPULATION CHARACTERISTICS: Low MCA Moderate MCA High MC

Age: 27.5% 65-69, 26% 70-74, 21% Age: 25% 65-69, 26% 70-74, 22% Age: 23% 

Mean age & range (years): 75-79, 14% 80-854, 11% 85+ 75-79, 15% 80-84, 12% 85+ 75-79, 13

Sex (% female): Race: 

Sex: 60% female Race: 91% White, 7% Black, 2% 

Sex: 61% female Race: 88% White, 9% Black, 3% 

Sex: 61% Race: 85% 

Other Other Other 

Other: 

All 

Attrition/Drop-out (not available for endpoint measurement): Adherence: 

NA 

Contamination: Response Rates (e.g. for surveys): 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY: Authors, ref ID: Koroukian, S.M., et al.31 

Year of publication: 2005 Dates of data collection: 1998-1999 Trial name: NA 

STATISTICAL ANALYSES: Describe: 

Conducted descriptive analyses to study the demographic profile and physician supply by 

presence of bivariate associations between categorical variables using x2 statistics. The authors used the individual as the unit of analysis, and obtained adjusted odds ratios multilevel logistic regression models to assess the likelihood of undergoing CRC screeninlevel, after controlling for individual- and county-level characteristics. 

ASSESSMENT OF EXPOSURES AND NR POTENTIAL CONFOUNDERS: OUTCOME ASSESSMENT: Outcome Measures: 

Procedure codes for FOBT, sigmoidoscopy, and colonoscopy. 

RESULTS: 

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KQ2 - What factors influence the use of colorectal cancer screening? 

Outcomes: Positive association between CRC screening and greater level of MCA, adjusting for counattributes and physician resources. Greater level of MCA associated with CRC screening: High vs. low MCA: • FOBT: AOR, 1.10 (95% CI, 1.04-1.16) 

• Colonoscopy: AOR, 1.07 (95% CI, 1.03-1.10) • FS: AOR, 0.98 (95% CI, 0.93-1.03) 

No absolute screening rates given.
 Moderate MCA was not associated with increased use of FLEX but was positively associameasures of colonoscopy.
 No consistent association between CRC screening and level of MCA
 

KQ3 - Which strategies are effective in Outcomes: NA increasing the appropriate use of colorectal cancer screening and followup? KQ4 - What are the current and Outcomes: NA projected capacities to deliver colorectal cancer screening and surveillance at the population level? KQ5 - What are the effective approaches Outcomes: NA 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY: Authors, ref ID: Koroukian, S.M., et al.31 

Year of publication: 2005 Dates of data collection: 1998-1999 Trial name: NA 

for monitoring the use and quality of colorectal cancer screening? QUALITY RATING: Fair 

Quality Assessment-Internal Validity for Observational Studies 

Yes No Other (CD, NR, 

Were the groups similar at baseline regarding the most important prognostic 

X 

indicators? Were the drop-out or response rates acceptable (≤ 20%)? [If between 20% NA and 60%, check other and explain.] Were the differential drop-out or response rates acceptable (≤ 15%)? NA 

Were intervention/exposure measures valid, reliable, and equally applied? X Were the outcome assessors blinded to the intervention or exposure status X 

of subjects? Were outcome measures valid, reliable, and equally applied? X Does the analysis control for baseline differences? X Were important potential confounding and modifying variables taken into X account in the design and analysis (e.g., through matching, stratification, or statistical adjustment)? Were the statistical methods used to assess the abstracted outcomes X But probably inaappropriate? Quality Rating (Good, Fair, or Poor): Fair Reviewer #1 initials: BLM Reviewer #2 initials: RPH Comments (explain poor quality ratings): 

C-117
 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

C-118
 

STUDY:	 Authors, ref ID: Koroukian, S.M., et al.32 

Year of publication: 2006 Dates of data collection: 1999 and 1998 Trial name: NA 

OBJECTIVE OR AIM: To assess the disparities in CRC screening between elderly dual Medicare-Medicaid enro

duals. 

DESIGN: Setting: 1999 Medicare Denominator File, the Medicare Outpatient Standard Analytic File

B files, 1998 Area resource File. Study design: Cross-sectional study Duration (mean followup): No follow-up Overall study size (N enrolled/N analyzed): 23 million Medicare beneficiaries Duals Non-duals 

Sample size: 2.5 million 20.2 million 

Describe intervention: No intervention RECRUITMENT: Population-based (population-based, clinic-based, volunteer, other) INCLUSION CRITERIA:	 Duals: Age 65+, reside in contiguous states and Hawaii, enrolled in Medicare for the entir

receiving care exclusively through the fee-for-service system Non-duals: No history of enrollment in the stat buy-in program for Part A and Part B, resid1,000 beneficiaries or 10,000 FFS months of enrollment in Medicare, whichever is more 

EXCLUSION CRITERIA:	 Duals: Not enrolled in the state buy-in program for Part A and Part B for all 12 months of t

POPULATION CHARACTERISTICS:	 Duals Non-duals 

Age: 22% 65-69, 23% 70-74, 20% Age: 26% 65-69, 27% 70-74, 22% 

Mean age & range (years): 75-79, 15% 80-84, 19% 85+ 75-79, 14% 80-84, 11% 85+ Sex (% female): Sex: 74% female Sex: 41% female 

Race: Race: 63% Caucasian, 21% African Race: 92% Caucasian, 5% African 

American, 16% Other American, 3% Other 

Other: Attrition/Drop-out (not available for NR 

endpoint measurement): Adherence:
 Contamination: Response Rates (e.g. for surveys): 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY: Authors, ref ID: Koroukian, S.M., et al.32 

Year of publication: 2006 Dates of data collection: 1999 and 1998 Trial name: NA 

STATISTICAL ANALYSES: Describe: 

Used x2 statistics to test for statistical significance in bivariate associations. Conducted stratified analyses and compared the proportions of duals and non-duals 

screening modalities with demographic categories. 

Calculated the age-race-sex adjusted rates of screening for duals and non-duals usin

method. 

Hierarchical logistic regression models Adjusted Ors were used to assess likelihood of undergoing CRC screening after cont

county-level characteristics. 

ASSESSMENT OF EXPOSURES AND POTENTIAL CONFOUNDERS: 

NR 

OUTCOME ASSESSMENT: Outcome Measures: 

Procedure codes for FOBT, flexible sigmoidoscopy, and colonoscopy. 

C-119
 RESULTS: 

KQ2 - What factors influence the use of colorectal cancer screening? 

Outcomes: 

Duals were significantly less likely to undergo CRC screening (P < 0.001) and was con

race, and sex strata, and procedural modalities. For all screening modalities, older age and African American race were associated wit

undergoing screening Men were less likely to undergo FOBT (OR = 0.72, CI: 0.68, 0.76), more likely to unde(OR=1.17, CI: 1.12, 1.22) or colonoscopy (OR=1.19, 1.15, 1.23). Use of CRC screening services decrease if dual enrollment in Medicare-Medicaid: FOB0.45-0.51), FS (AOR, 0.55; 95% CI, 0.49-0.61), FS or colonoscopy (AOR, 0.60; 95% C(AOR, 0.85; 95% CI, 0.80-0.89 

KQ3 - Which strategies are effective in Outcomes: NA increasing the appropriate use of colorectal cancer screening and followup? KQ4 - What are the current and Outcomes: NA projected capacities to deliver colorectal cancer screening and 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY: Authors, ref ID: Koroukian, S.M., et al.32 

Year of publication: 2006 Dates of data collection: 1999 and 1998 Trial name: NA 

surveillance at the population level? KQ5 - What are the effective approaches for monitoring the use and quality of colorectal cancer screening? 

Outcomes: NA 

C-120
 

QUALITY RATING: Fair Quality Assessment-Internal Validity for Observational Studies 

Yes No Other (CD, NR, 

Were the groups similar at baseline regarding the most important prognostic 

X 

indicators? Were the drop-out or response rates acceptable (≤ 20%)? [If between 20% NA and 60%, check other and explain.] Were the differential drop-out or response rates acceptable (≤ 15%)? NA 

Were intervention/exposure measures valid, reliable, and equally applied? NA Were the outcome assessors blinded to the intervention or exposure status NA of subjects? Were outcome measures valid, reliable, and equally applied? X Does the analysis control for baseline differences? X Were important potential confounding and modifying variables taken into X account in the design and analysis (e.g., through matching, stratification, or statistical adjustment)? Were the statistical methods used to assess the abstracted outcomes X appropriate? Quality Rating (Good, Fair, or Poor): Fair Reviewer #1 initials: BLM Reviewer #2 initials: DJH Comments (explain poor quality ratings): 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

C-121
 

STUDY:	 Authors, ref ID: Lemon, S., et al. 33 Year of publication: 2001 

Dates of data collection: June-August 1998 Trial name: NA 

OBJECTIVE OR AIM: The relation of personal characteristics, health and lifestyle behaviors, and cancer screen

colorectal cancer (CRC) screening was assessed and compared with those factors’ relatiomammography screening in women and prostate-specific antigen (PSA) screening in men

DESIGN: Setting: State 

Study design: Cross-sectional survey Duration (mean followup): None Overall study size (N enrolled/N analyzed): 954 All 

Sample size: N = 954 

Describe intervention: Intervention: None, random digit dial survey RECRUITMENT: Population-based; random digit dial 

(population-based, clinic-based, volunteer, other) INCLUSION CRITERIA: Massachusetts residents 50 years and older who were cognitively able, resided in a home 

number, and had never been diagnosed with CRC 

EXCLUSION CRITERIA:	 Men ever diagnosed with prostate cancer and women ever diagnosed with breast cancer 

POPULATION CHARACTERISTICS:	 All 

Age: 52.6% 50-64, 27.8% 65-74, 19.6% 75-84 

Mean age & range (years): Sex: 56.6% female Sex (% female): Race: 91% White, 9% Other Race: Other: 

All 

Attrition/Drop-out (not available for Among 1747 eligible persons contacted, 1119 (64%) completed the survey; 954 analyzed endpoint measurement): Adherence: Contamination: Response Rates (e.g. for surveys): STATISTICAL ANALYSES: Describe: 

•	 Univariate analyses were used to describe the study sample and screening 

total sample and in the analyses stratified by sex, bivariate x2 statistics and o

confidence intervals, were used to document the crude relationship between and CRC screening status. 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY:	 Authors, ref ID: Lemon, S., et al. 33 Year of publication: 2001 

Dates of data collection: June-August 1998 Trial name: NA 

• Logistic regression was used to model the association between each outcom

lifestyle behavior. 

ASSESSMENT OF EXPOSURES AND Personal characteristics were considered potential confounders if they were marginally as

POTENTIAL CONFOUNDERS: or the exposure variables in bivariate analyses or were strongly associated in prior literatu

Variables included: Demos (age, race, ethnicity, gender, marital status, education) Health factors (family history) Access (income, insurance, regular check-ups) Health/risk behavior (vitamin supplement use, screening practices, smoking) 

OUTCOME ASSESSMENT: Outcome Measures: 

•	 Patient experiences with FOBT, colonoscopy, and sigmoidoscopy 

•	 Persons were considered currently screened on the basis of recent guideline

had 1 or more of the following: (1) a fecal occult blood test within the previousigmoidoscopy within the previous 5 years; (3) colonoscopy within the previocontrast barium enema within the previous 10 years. This definition included 

CRC test for screening as well as for diagnostic reasons. 

RESULTS: KQ2 - What factors influence the use of Outcomes: colorectal cancer screening? • While neither sex nor education had an independent effect, an interaction be

emerged. Compared with men with a college degree or higher, those with lediploma (OR=0.11; 95% CI=0.04, 0.32; p=.001) and men with high school dtrade school (OR=0.31; 95% CI=0.15, 0.64; p=.002) were less likely to be cu

• Family history of CRC was an independent predictor of screening (OR=1.98

0.04). 

• Compared with those with private, non-HMO insurance, members of Medica

significantly more likely to be currently screened (OR=2.25; 95% CI=1.13, 4

• Men and women who were currently screened for PSA and mammography, 

likely to be screened for CRC than those who were not (OR=4.40; 95% CI=2

• Those who had a regular checkup (OR=3.07; 95% CI=2.00, 4.71; p<.001) a

users (OR=1.87; 95% CI=1.27, 2.77; p=.02) had higher screening rates. 

KQ3 - Which strategies are effective in increasing the appropriate use of colorectal cancer screening and followup? 

NA 

KQ4 - What are the current and NA projected capacities to deliver 

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Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY: Authors, ref ID: Lemon, S., et al. 33 Year of publication: 2001 

Dates of data collection: June-August 1998 Trial name: NA 

colorectal cancer screening and surveillance at the population level? KQ5 - What are the effective approaches for monitoring the use and quality of colorectal cancer screening? 

NA 

QUALITY RATING: Fair Quality Assessment-Internal Validity for Observational Studies 

Yes No Other (CD, NR, N

Were the groups similar at baseline regarding the most important prognostic NA indicators? Were the drop-out or response rates acceptable (≤ 20%)? [If between 20% and Among 1747 eligi

60%, check other and explain.] 1119 (64%) compWere the differential drop-out or response rates acceptable (≤ 15%)? NA 

Were intervention/exposure measures valid, reliable, and equally applied? NA Were the outcome assessors blinded to the intervention or exposure status of NA 

subjects? Were outcome measures valid, reliable, and equally applied? X Does the analysis control for baseline differences? X Were important potential confounding and modifying variables taken into account in X the design and analysis (e.g., through matching, stratification, or statistical adjustment)? Were the statistical methods used to assess the abstracted outcomes appropriate? X 

Quality Rating (Good, Fair, or Poor): Fair 

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Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

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STUDY:	 Authors, ref ID: Levy, B.T., et al.34 

Year of publication: 2006 Dates of data collection: chart reviews were conducted from May to SeptembeTrial name: 

OBJECTIVE OR AIM: The purpose of this study was to examine patient and physician factors associate

CRC testing according to national guidelines. 

DESIGN: Setting: Cross-sectional study 

Study design: Secondary data analysis Duration (mean followup): 2004-2006 Overall study size (N enrolled/N analyzed): 511 

Sample size: 511 

Describe intervention: NA RECRUITMENT: Clinic-based; Participating physicians provided lists of their patients aged 55 to 8(population-based, clinic-based, volunteer, other) INCLUSION CRITERIA:	 55-80 years EXCLUSION CRITERIA: Physicians: Patients primarily below age 50 

POPULATION CHARACTERISTICS: Mean age & range (years): Age range: 55-80; Mean age: 68.1 Sex (% female): NR Race: 99% White Attrition/Drop-out (not available for Overall: 

endpoint measurement): 59% returned study materials Adherence: Contamination: Response Rates (e.g. for surveys): 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY:	 Authors, ref ID: Levy, B.T., et al.34 

Year of publication: 2006 Dates of data collection: chart reviews were conducted from May to SeptembeTrial name: 

STATISTICAL ANALYSES: Describe: 

The generalized estimating equations (GEE) approach in SAS PROC GENMOD odds ratios (ORs) and 95% confidence intervals (CIs) for potential predictors of saccount random effects due to physicians.
 

ASSESSMENT OF EXPOSURES AND POTENTIAL CONFOUNDERS: OUTCOME ASSESSMENT: Outcome Measures: 

•	 The main outcome variable was whether a patient was up-to-date with C

medical record review. 

•	 “Up-to-date” was defined as any of the following within the time interval n

mailing date: five take-home hemoccult tests within the previous 5.5 yeaprevious 5.5 years, barium enema within the previous 5.5 years, or colonprevious 10.5 years. 

•	 The overall CRC testing rate was defined as (number of patients with up

(total number of patients). 

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 RESULTS: 

KQ2 - What factors influence the Outcomes: use of colorectal cancer screening? • Overall, 76% of patients stated that their physician had ever recommend

71% reporting that they had completed at least one of the CRC tests. 

• Based on medical record review, 55% of patients had physician docume

screening discussion, 64% had completed at least one CRC test ever, 54least one CRC test in the past 5.5 years, and 46% were up-to-date with C

• Not including hemoccults, of the 234 patients up-to-date with screening, 

screened and 144 (62%) were tested because of symptoms. 

• Results, Patient self-report, Hemoccult X 3, Doc ever recommend?, 265 

Recommended test?, 231 (45.2) vs Medical record review, Hemoccult X 87 (17.0); At least one test ever completed, 183 (35.8); Up-to-date with tcurrent tests done for screening, unable to calculate; Patient self-report, recommend?, 129 (25.2); Completed Recommended test?, 114 (22.3) vs FS, MD recommended, 61 (11.9); At least one test ever completed, 80 (1test, 25 (4.9); Proportion of current tests done for screening, 15 (60.0); PColonoscopy, Doc ever recommend?, 295 (57.7); Completed recommenMedical record review, Colonoscopy, MD recommended, 220 (43.1); At 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

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STUDY:	 Authors, ref ID: Levy, B.T., et al.34 

Year of publication: 2006 Dates of data collection: chart reviews were conducted from May to SeptembeTrial name: 

completed, 225 (44.0); Up-to-date with test, 208 (40.7); Proportion of curscreening, 60 (28.9), Patient self-report, Any colon cancer screening testrecommend?, 389 (76.1); Completed recommended test?, 360 (70.5) vs Any colon cancer screening test, MD recommended, 279 (54.6); At leascompleted, 328 (64.2); Up-to-date with test, 234 (45.8); Proportion of curscreening, 90 (38.5) (not including hemoccults); Physician Predictors, Parecommendation, No, 218 (20.6); Yes, 283 (64.7); OR (95% CI), 6.4 (4.2documented CRC discussion, No, 232 (14.7); Yes, 279 (71.7); OR (95% 

<0.001; Patient Perceptions/Satisfied with: Doctor’s discussions of scree123 (27.6); High, 310 (59.7); OR (95% CI), 3.6 (2.5–5.3); P <0.001; MD Dscreening options; Low, 152 (33.6); High, 266 (60.5); OR (95% CI), 2.8 (Input into the screening decision; Low, 144 (34.0); High, 261 (61.7) OR (P <0.001; MD Comfort in asking doctor questions about CRC screening; 400 (52.5); OR (95% CI), 3.1 (1.7–5.4); P <0.001; MD; Satisfied with docscreening importance: CRC testing (up-to-date), N, 511; OR (95% CI), 3Asymptomatic screening, N, 367; OR (95% CI), 3.0 (1.8–5.1); P <0.001; 421; OR (95% CI), 3.8 (2.5–5.7); P <0.001 

KQ3 - Which strategies are effective NA in increasing the appropriate use of colorectal cancer screening and followup? KQ4 - What are the current and NA projected capacities to deliver colorectal cancer screening and surveillance at the population level? KQ5 - What are the effective NA approaches for monitoring the use and quality of colorectal cancer screening? QUALITY RATING: Fair 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

Quality Assessment-Internal Validity for Observational Studies 

Yes No Other (CD, NR, NA) 

Were the groups similar at baseline regarding the most Yes, if you consider the statistic adjustments 

important prognostic indicators? Were the drop-out or response rates acceptable (≤ 20%)? [If 

X 

59% returned study materials 

between 20% and 60%, check other and explain.] Were the differential drop-out or response rates acceptable (≤ NA 

15%)? Were intervention/exposure measures valid, reliable, and NA equally applied? Were the outcome assessors blinded to the intervention or NA exposure status of subjects? 

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Were outcome measures valid, reliable, and equally applied? X They looked for 5 FOBT within 5.5 years to b

rather than 1 in the past 1 year. 

Does the analysis control for baseline differences? X Were important potential confounding and modifying X variables taken into account in the design and analysis (e.g., through matching, stratification, or statistical adjustment)? Were the statistical methods used to assess the abstracted X outcomes appropriate? Quality Rating (Good, Fair, or Poor): Fair 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

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STUDY:	 Authors, ref ID: Ling, B.S., et al.35 

Year of publication: 2006 Dates of data collection: 2002-2003 Trial name: Health Information National Trends Survey (HINTS) 

OBJECTIVE OR AIM: Assessed the association between provider–patient interaction with colorectal cancer scre

compared the information seeking patterns, sources of information, trust in cancer informaamong respondents who were up to date with colorectal cancer screening with those who 

DESIGN: Setting: Telephone survey 

Study design: Cross-sectional, econdary data analysis Duration (mean followup): 2002-2003 administration of the HINTS Overall study size (N enrolled/N analyzed): 2,670 respondents 

Sample size: 2,670 respondents Describe intervention: RECRUITMENT: List-assisted random digit dialing (population-based, clinic-based, volunteer, other) INCLUSION CRITERIA:	 51 years and greater 

EXCLUSION CRITERIA:	 Those 50 or younger; prior personal history of CRC POPULATION CHARACTERISTICS:	 Sample Mean age & range (years): Age: 51+; 39.6% 51-60, 29.3% 61-70, 30.1% 71+ Sex (% female): Sex: 63.1% female Race: Race: 80% White, 10.5% African American, 9.5% Other 

Other: Attrition/Drop-out (not available for Overall response rate 62.8%
 

endpoint measurement): Adherence:
 Contamination: Response Rates (e.g. for surveys): STATISTICAL ANALYSES: Describe: 

Descriptive statistics were generated for all variables as frequencies or means. Chi-square tests were conducted to assess for significant differences in the primary outcothe categorical variables The association between continuous variables and the primary outcome was assessed us
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY: Authors, ref ID: Ling, B.S., et al.35 

Year of publication: 2006 Dates of data collection: 2002-2003 Trial name: Health Information National Trends Survey (HINTS) Wilcoxon rank-sum test. For those communication=information-related items found significantly associated with cobehavior, logistic regression models were used to assess for adjusted effect after controllicharacteristics. 

ASSESSMENT OF EXPOSURES AND NR POTENTIAL CONFOUNDERS: OUTCOME ASSESSMENT: Outcome Measures: 

Provider-patient interaction, information seeking, channel reliance, channel credibility, intecancer screening behavior measures The primary outcome variable was colorectal cancer screening defined as being up to dat

RESULTS: KQ2 - What factors influence the use of colorectal cancer screening? 

Outcomes: No statistically significant differences were seen between the up-to-date and not-up-to-da

provider–patient interaction items (“the provicer always: listens carefully, explains things, senough time, involves patients in decisions”. Conversely, for information seeking, the up-to-date group had a statistically significant higsought cancer information (52.9% vs. 36.8%, P<.001) and had others do the information sP<.001). Significant differences were seen in the percentage of respondents between the groups in information from personalized reading materials (p<.05) and publications (P<.001). As for trust in cancer information from specific sources, an overwhelming percentage trus

up-to-date (95.4%) and not-up-to-date (88.4%) groups, with a significant difference seen b(P<.001). When asked about Internet usage, among those who go on-line, 63% in the up-to-date grinformation compared with the 54.8% who are not up to date (P<.01). Logistic regression models showed that having trust in cancer information from the doctor being up to date (OR 2.08, 95% CI 1.49–2.94). Other items remaining significantly associated with being up to date included the followinginformation, had others search for cancer information, desired cancer information from pematerials or a publication, and used the Internet for cancer information. Trust in MD associated with greater screening. Other interaction items not significant. 

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Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY: Authors, ref ID: Ling, B.S., et al.35 

Year of publication: 2006 Dates of data collection: 2002-2003 Trial name: Health Information National Trends Survey (HINTS) 

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KQ3 - Which strategies are effective in Outcomes: NA increasing the appropriate use of colorectal cancer screening and followup? KQ4 - What are the current and Outcomes: NA projected capacities to deliver colorectal cancer screening and surveillance at the population level? KQ5 - What are the effective approaches Outcomes: NA for monitoring the use and quality of colorectal cancer screening? QUALITY RATING: Fair Quality Assessment-Internal Validity for Observational Studies 

Yes No Other (CD, NR, 

Were the groups similar at baseline regarding the most important prognostic indicators? NA Were the drop-out or response rates acceptable (≤ 20%)? [If between 20% and 60%, 

X 

response rate 62

check other and explain.] Were the differential drop-out or response rates acceptable (≤ 15%)? NA 

Were intervention/exposure measures valid, reliable, and equally applied? NA Were the outcome assessors blinded to the intervention or exposure status of subjects? NA 

Were outcome measures valid, reliable, and equally applied? X Does the analysis control for baseline differences? X Were important potential confounding and modifying variables taken into account in the X 

design and analysis (e.g., through matching, stratification, or statistical adjustment)? Were the statistical methods used to assess the abstracted outcomes appropriate? X Quality Rating (Good, Fair, or Poor): Fair Reviewer #1 initials: BLM Reviewer #2 initials: MJG Comments (explain poor quality ratings): 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

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STUDY:	 Authors, ref ID: Matthews, B., et al.36 

Year of publication: 2007 Dates of data collection: Spring 2005 Trial name: NA 

OBJECTIVE OR AIM: The purpose of this study was to examine potential indicators of success in a geographic 

previously shown relatively high CRC screening rates. Our goal was to survey a represenapproximately 1050 age-appropriate southeastern Wisconsin residents regarding their hecurrent CRC screening status. 

DESIGN: Setting: Wisconsin, telephone survey 

Study design: Cohort survey study Duration (mean followup): No follow-up Overall study size (N enrolled/N analyzed): 1,068 interviews completed/1,033 interviewAll 

Sample size: Sample size: 1,033 

Intervention: None, survey 

Describe intervention: RECRUITMENT: Population-based, random digit dial 

(population-based, clinic-based, volunteer, other) INCLUSION CRITERIA:	 Age between 50-79, English proficiency, and informed consent for research participation. 

EXCLUSION CRITERIA:	 Only one person per household, previous diagnosis of CRC 

POPULATION CHARACTERISTICS:	 All Mean age & range (years): Age: 52.9% 50-64, 47.1% 65-79 Sex (% female): Sex: 56.1% female Race: Race: 9.3% Other, 90.7% White Other: 

All 

Attrition/Drop-out (not available for Simple response rate of 88% endpoint measurement): Using CASRO formula the response rate was 60.7%. Adherence: Contamination: Response Rates (e.g. for surveys): STATISTICAL ANALYSES: Describe: 

Contingency tables (v2) were used to test bivariate relations; logistic regression was used models. Because of the large number of potential indicators, authors used bivariate analybe included in multivariate analyses 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY:	 Authors, ref ID: Matthews, B., et al.36 

Year of publication: 2007 Dates of data collection: Spring 2005 Trial name: NA 

ASSESSMENT OF EXPOSURES AND Variables included: 

POTENTIAL CONFOUNDERS: Demographics (county of residence, age, gender, race, education) 

Health care (have regular MD, freq of visits, annual physicals, MD recomm for screening) Health factors (screening behavior, family/personal history, exercise, eating) Access (health insurance) Care behavior/pscyho (worries about cancer) KABRs (knowledge of CRC, beliefs, locus of control) 

OUTCOME ASSESSMENT: Outcome Measures: 

FOBT within 12 months preceding the survey, FS within 5 years, or CS within 10 years 

RESULTS: 

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KQ2 - What factors influence the use of colorectal cancer screening? 

Outcomes: Adults 65 to 79 were more than twice as likely to report up-to-date test use as adults age 

CI = 1.76–3.21) Respondents who reported visiting a physician regularly were more likely to report being c(AOR 2.02; 95% CI, 1.49-2.74) Respondents were more likely to be screened if they believed the tests are safe (AOR, 1.3

it’s irresponsible not to get tested (AOR, 2.16; 95% CI, 1.67-2.78); or had a positive attitud

general (AOR, 2.35; 95% CI, 1.76-3.13); P-values 0.05 or better Respondents were less likely to be screened if they had anxiety about the tests (AOR, 0.5believed that if they are healthy, they don’t need to be tested (AOR, 0.58; 95% CI, 0.42-0.The odds of up-to-date screening test use increased twofold among individuals who reporon a regular basis (OR = 2.11; 95% CI = 1.41–3.16), for those at higher risk for CRC beca

risk factors (OR = 2.26, 95% CI = (1.47–3.49), and among those who reported using their 

source of health information (OR = 2.27, 95% CI = 1.33–3.90). The odds of up-to-date screening test use increased about 68% among individuals who pscreening tests such as breast or prostate cancer exams (OR = 1.68, 95% CI = (1.20–2.3Adherence, as reflected by compliant attitudes toward physician recommendation to test f= 1.75–3.67), and responsibility to test for CRC by age 55 showed the strongest effects, incurrent testing by about 150% to 140%, respectively, compared to non-current test use. The odds of current testing decreased about 40% among respondents reporting greater aprocedures (OR = 1.40 , 95% CI = 1.02–1.92) and about 48% among those who thought t
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY:	 Authors, ref ID: Matthews, B., et al.36 

Year of publication: 2007 Dates of data collection: Spring 2005 Trial name: NA healthy people to test for CRC (OR = 0.52, 95% CI = 0.35–0.77). 

KQ3 - Which strategies are effective in Outcomes: NA increasing the appropriate use of colorectal cancer screening and followup? KQ4 - What are the current and Outcomes: NA projected capacities to deliver colorectal cancer screening and surveillance at the population level? KQ5 - What are the effective approaches Outcomes: NA for monitoring the use and quality of colorectal cancer screening? QUALITY RATING: Fair 

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C-134
 

Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) Quality Assessment-Internal Validity for Observational Studies 

Yes No Other (CD, 

Were the groups similar at baseline regarding the most important prognostic indicators? NA 

Were the drop-out or response rates acceptable (≤ 20%)? [If between 20% and 60%, check Simple respother and explain.] Using CASR

response ra

Were the differential drop-out or response rates acceptable (≤ 15%)? NA Were intervention/exposure measures valid, reliable, and equally applied? NA 

Were the outcome assessors blinded to the intervention or exposure status of subjects? NA Were outcome measures valid, reliable, and equally applied? X Does the analysis control for baseline differences? NA Were important potential confounding and modifying variables taken into account in the X design and analysis (e.g., through matching, stratification, or statistical adjustment)? Were the statistical methods used to assess the abstracted outcomes appropriate? X Quality Rating (Good, Fair, or Poor): Fair Reviewer #1 initials: BLM Reviewer #2 initials: DJH Comments (explain poor quality ratings): 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

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STUDY: Are there gender differences in	 Authors, ref ID: McQueen, et al.37 colorectal cancer test use prevalence and Year of publication: 2006 

correlates	 Dates of data collection: Data from 2002 to 2003 HINTS used 

Trial name: data from HINTS used 

OBJECTIVE OR AIM: Addressed the following questions: (a) Are prevalence rates for lifetime, recent, and repea

similar for males and females? (b) Are the demographic, health status, access to health ccorrelates of FOBT and endoscopy use previously reported in the literature similar for mathe patterns of these correlates similar to findings from other national surveys? (d) Are psHINTS, including knowledge, cancer-related beliefs, and cancer communication, associatendoscopy use, and are the associations similar for males and females? 

DESIGN: Setting: US 

Study design: cross sectional; HINTS was a cross-sectional study conducted from 2002 digit dialing Duration (mean followup): data collected for 1 year, no follow-up data reported Overall study size (N enrolled/N analyzed): 2686 

Sample size: Of the 6,369 telephone surveys completed by adults ages >= 18 years, 2,734 were ages >

2,686 had no personal history of colon or rectal cancer and comprised the 

Describe intervention: NA	 sample used in this report 

NA 

RECRUITMENT: Population based through telephone interviews: random digit dialing (population-based, clinic-based, volunteer, other) INCLUSION CRITERIA:	 One adult (>=18 years) per household was eligible to participate. 

EXCLUSION CRITERIA:	 Personal history of colon or rectal cancer 

POPULATION CHARACTERISTICS: 

63% were female and 74% were non-Hispanic White. The average age was 64.4 years o

Mean age & range (years): ranged from 50 to 95 years Sex (% female): Race: Other: Attrition/Drop-out (not available for Telephone interviewers were able to reach 19,509 households. The final response rate foendpoint measurement): interview was 55%, calculated according to the guide of Standard Definitions published by Adherence: Association for Public Opinion Research. The final response rate for the full HINTS interv

Contamination: details of the sampling plan are reported 

elsewhere 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY: Are there gender differences in Authors, ref ID: McQueen, et al.37 colorectal cancer test use prevalence and correlates 

Year of publication: 2006 Dates of data collection: Data from 2002 to 2003 HINTS used Trial name: data from HINTS used 

Response Rates (e.g. for surveys): 

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STATISTICAL ANALYSES: Telephone exchanges were geographically stratified to oversample from exchanges estim

American and Hispanic residents. Final data were weighed to be nationally representativeStratified analyses by gender instead of testing interactions with gender to explore differeassociations. Descriptive analyses were conducted using SAS and Survey Data Analysis observed sample sizes and weighed percentages. Prevalence of Colorectal Cancer Test Use: Examined colorectal cancer test use prevallifetime, recent, and repeat use of home FOBT, sigmoidoscopy, and colonoscopy alone aas whether any of the three tests had been completed. Used 95% confidence intervals (95rates for males and females. Prevalence estimates were age adjusted. The denominator f

cancer test use was restricted to respondents who would be eligible to complete two screFOBTs within 2 years or two endoscopy tests within 20 years). Conducted analyses using replicate weight jackknife estimate of variance to account for the sampling design and to c

population estimates; therefore, the results reflect weighed and design-adjusted data. Addcompleting a colorectal cancer test have been previously reported but have not been exadifferences. Identifying gender-specific and test-specific barriers to colorectal cancer test 

future interventions designed to increase colorectal cancer test use. To explore whether rtested differed by gender, conducted descriptive analyses with a subset of respondents wprovider in the past year but had not had a colorectal cancer test within recommended timcould give multiple reasons for not having had a FOBT or endoscopy. Categorized responsystem level factors following Klabunde et al. (25). Correlates of Colorectal Cancer Test Use. Used multivariable logistic regression analysexamine correlates of colorectal cancer test use by gender and test type (FOBT and endofour regression models (one for each combination). Two dependent variables were home year and recent endoscopy (i.e., sigmoidoscopy or colonoscopy in the past 10 years). The variables was no colorectal cancer test of any type within recommended intervals. Used Osummarize the results. CIs for males and females that do not overlap may suggest gendeAnalysis Strategy. To facilitate comparison with other national surveys, used a two-step four regression models. In step 1, examined variables measuring demographics, access tstatus, and health behaviors that have been previously examined with nationally represenexplored whether their associations with colorectal cancer test use differed by gender. Costatistically significant (P < 0.05) in at least one of the four models in step 1 were retained models. In step 2, added variables from the HINTS that have not been previously examine

knowledge, beliefs, and cancer communication). Family history of cancer has been consiscolorectal cancer test use in the literature and was retained in step 2, although it was not 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY: Are there gender differences in	 Authors, ref ID: McQueen, et al.37 colorectal cancer test use prevalence and Year of publication: 2006 

correlates	 Dates of data collection: Data from 2002 to 2003 HINTS used 

Trial name: data from HINTS used step 1. Because results did not change when this variable was removed from analyses, chcomparisons with other studies. Effect estimates with cell sizes V 5 were not presented. ‘‘

responses were included when the percent of missing data was large and potentially meaperceived risk) or when ‘‘don’t know’’ was similar in meaningto a valid ‘‘no opinion’’ responbeliefs). 

ASSESSMENT OF EXPOSURES AND HINTS survey collected information on: demographic variables, access to health care, hePOTENTIAL CONFOUNDERS: behaviors, knowledge of CRC screening guidelines, beliefs about cancer risk, beliefs abo

use, beliefs about cancer in general, “cancer worry”, “degree to which participants paid attmedical topics via television, radio, newspapers, magazines, or the Internet”, trust in inforsources, trust in healthcare providers/family/friends for cancer information, cancer informa

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OUTCOME ASSESSMENT: To assess colorectal cancer test use, individuals were first read a description of one of thr

FOBT, sigmoidoscopy, and colonoscopy) and asked whether they had ever heard of the tRespondents who had heard of the test were then asked whether they had ever had the twhen the test was completed, and when the next-to-last test was completed. Persons who both sigmoidoscopy and colonoscopy were asked to report when their most recent endosThe survey did not distinguish which endoscopy test was the most recent and so responsprocedure. Individuals were considered currently adherent to guidelines for colorectal canhaving a home FOBT within the past year or endoscopy within the past 10 years. Use of denema was not assessed in the HINTS. 

RESULTS: KQ2 - What factors influence the use of colorectal cancer screening? 

Females reported slightly higher lifetime (ever) and recent use of FOBT than males (17.1% for female; and 12.1% lifetime and 5.2% recent for male) Males and females who visited a physician 1 or more times in the previous year were morendoscopy than those with no visits in the prior year (AOR 5.12; 95% CI, 2.54-10.29 and 13.37, respectively; P < 0.05) “Not having a doctor” was associated with not being screened for CRC in both males (AOFOBT and OR, 0.5; 95% CI, 0.1-1.9 for endoscopy) and females (AOR, 0.2; 95% CI, 0.1-095% CI, 0.2-1.4 for endoscopy) Males and females were more likely to be screened if they understood the appropriate tim(AOR, 5.42; 95% CI, 2.52-11.66 for males and AOR, 5.25; 95% CI, 3.23-8.52 for female) 4.69; 95% CI, 2.55-8.65 and AOR, 3.18; 95% CI, 2.26-4.47, respectively) Females were more likely to be screened if they believed they were more likely than otheCRC (AOR, 2.53; 95% CI, 1.43-4.46 for endoscopy); if they believed CRC testing leads to 3.03; 95% CI, 1.03-8.93 for FOBT); or if they had a fear of finding cancer (AOR, 1.78; 95% 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY: Are there gender differences in	 Authors, ref ID: McQueen, et al.37 colorectal cancer test use prevalence and Year of publication: 2006 

correlates	 Dates of data collection: Data from 2002 to 2003 HINTS used 

Trial name: data from HINTS used 

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Males and females were less likely to be screened if they didn’t know if the tests were too 0.24-0.78 and 0.46; 95% CI, 0.30-0.71 for endoscopy, respectively) Females were also less likely to be screened with FOBT if they believed it was too expens0.32-0.93) or didn’t know the costs (AOR, 0.46; 95% CI, 0.27-0.79) All P values < 0.05 

KQ3 - Which strategies are effective in Outcomes: NA increasing the appropriate use of colorectal cancer screening and followup? KQ4 - What are the current and Outcomes: NA projected capacities to deliver colorectal cancer screening and surveillance at the population level? KQ5 - What are the effective approaches Outcomes: NA for monitoring the use and quality of colorectal cancer screening? QUALITY RATING: Good 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

Quality Assessment-Internal Validity for Observational Studies 

Yes No Other (CD, NR, 

C-139
 

Were the groups similar at baseline regarding the most important prognostic n/a 

indicators? Were the drop-out or response rates acceptable (≤ 20%)? [If between 20% x As mentioned, r

and 60%, check other and explain.] HINTS interview Were the differential drop-out or response rates acceptable (≤ 15%)? n/a 

Were intervention/exposure measures valid, reliable, and equally applied? x Were the outcome assessors blinded to the intervention or exposure status n/a 

of subjects? Were outcome measures valid, reliable, and equally applied? x Self-report may 

screening, but thall participants 

Does the analysis control for baseline differences? x Were important potential confounding and modifying variables taken into x account in the design and analysis (e.g., through matching, stratification, or statistical adjustment)? Were the statistical methods used to assess the abstracted outcomes x appropriate? Quality Rating (Good, Fair, or Poor): good Reviewer #1 initials: MJG Reviewer #2 initials: DJH Comments (explain poor quality ratings): 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY:	 Authors, ref ID: Messina, CR, et al.38 

Year of publication: 2009 Dates of data collection: October 2004 – January 2005 (Group 1), April 2004 – July 200Trial name: NA 

OBJECTIVE OR AIM: To examine the use of CRC screening exam modalities among county health centers and 

where both were located in the same geographic area. 

DESIGN: Setting: telephone survey of Suffolk County, New York residents 

Study design: Cross-sectional Duration (mean follow-up): NA Overall study size (N enrolled/N analyzed): N = 1070 enrolled and analyzed 

Group 1 (County Health Center Group 2 (Private Physician Patient) 

Sample size: Patient) 

n = 570 n = 570 

Describe intervention: NA (no intervention – cross- NA 

sectional telephone survey) 

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RECRUITMENT: (population-based, clinic-based, volunteer, other) 

Population-based – details: Group 1: The authors randomly selected participants from sampling frame of adults who w

screening and who received primary care at Suffolk county health centers. They stratified by health center to balance proportions of participants from each. Group 2: The authors obtained data for the random population-based private physician pa

NCI-funded Reducing Barriers to Colorectal Cancer Screening Project. They oversampled and conducted random selection in blocks stratified on gender and age group. 

INCLUSION CRITERIA:	 Group 1: (1) be without a prior diagnosis of CRC, colonic polyps, or other colorectal diagn

rather than screening in the general population (e.g., UC or Crohn’s); (2) not be too impai(3) consent to the telephone survey; (4) speak either English or Spanish; (5) age-eligible freceive care at the county health centers. Group 2: Same as above but only included English speaking participants 

EXCLUSION CRITERIA: Group1: none listed 

Group 2: none listed 

POPULATION CHARACTERISTICS: Group 1	 Group 2 

Female: 68% Female: 59% 

Mean age & range (years): 

Sex (% female): Age 52–64 (vs. 65–75): 76% (n = Age 52–64 (vs. 65–75): 48% (n =
 Race: 382) 270) Other: Race/ethnicity Race/ethnicity 

White (non-Hispanic): 47% Hispanic: White (non-Hispanic): 94% Hispanic: 29% <1% African American (non-Hispanic): African American (non-Hispanic): 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY:	 Authors, ref ID: Messina, CR, et al.38 

Year of publication: 2009 Dates of data collection: October 2004 – January 2005 (Group 1), April 2004 – July 200Trial name: NA 20% 

Other: 5% Education <HS: 34% HS graduate: 32% Post HS/trade school/technical school/some college: 22% ≥ College degree: 10% Annual household income <$15,000: 50%
 $15,000–$24,999: 25% $25,000–$44,999: 16% ≥ $45,000: 9% Medical insurance coverage No insurance: 44% Medicare/Medicaid: 49% Other commercial: 6% HMO: 2% Survey language English (vs.
 Spanish): 80%
 

4% Other: 2% Education <HS: 4% HS graduate: 29% Post HS/trade school/technical school/some college: 29% ≥ College degree: 38% 

Annual household income <$15,000: 5% $15,000–$24,999: 7% $25,000–$44,999: 17% ≥ $45,000: 71% 

Medical insurance coverage No insurance: 3% Medicare/Medicaid: 5% Other commercial: 59% HMO: 33% Survey language English (vs.
 Spanish): 100%
 

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Attrition/Drop-out (not available for endpoint measurement): Adherence: 

Group 1 

NA 

Group 2 

NA 

Contamination: Response Rates (e.g. for surveys): Response Rate: 52% Response Rate: 47% STATISTICAL ANALYSES: Describe: 

Bivariate cross-tabular analyses and Chi-square tests of association were used to examinsource of primary care, participant characteristics, CRC screening, and barriers to screenstratified by age group identified potential confounders. 

Logistic regression analyses were used to evaluate the probability of reporting recent scre

modality separately, for the health center and private practice patient samples. All particip
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY:	 Authors, ref ID: Messina, CR, et al.38 

Year of publication: 2009 Dates of data collection: October 2004 – January 2005 (Group 1), April 2004 – July 200Trial name: NA included in the multivariate model. They computed odds ratios from maximum-likelihood pcalculated 95% confidence intervals. They reported the Nagelkerke R2 as an indicator of t

explanatory variables to predict CRC screening. 

ASSESSMENT OF EXPOSURES AND Multivariate logistic regression controlled for potential covariate effects of sociodemograph

POTENTIAL CONFOUNDERS: screening barrier variables OUTCOME ASSESSMENT: Outcome Measures: 

They determined CRC screening exam use by responses to questions asking whether the FOBT, sigmoidoscopy, or colonoscopy, and the date of each most recent exam. They basFOBT and sigmoidoscopy on guidelines from the ACS, the Interdisciplinary Task Force, a

Services Task Force 

RESULTS: KQ2 - What factors influence the use of colorectal cancer screening? 

Outcomes: • Overall (considering the three screening modalities), the private physician patient sam

screening than the county health center registrants (70% vs. 55%, P < 0.001). While county health center registrants reported an FOBT in the past year (37% vs. 31%, P < were more likely to report a recent endoscopy (59% vs. 33%, P < 0.001). 

• For the most part, the authors did not find CRC screening disparities associated with 

sociodemographic variables or self-reported health status in adjusted analyses. Excefollows: 

• County health center participants with a college education were significantly more like

sigmoidoscopy than those with less than a college education (AOR = 3.23, 95% CI (1

• Among county health center participants, other commercial/HMO insurance coverage 

significantly with lower odds of FOBT (OAR = 0.35, 95% CI (0.14 – 0.91) P = 0.02), wsignificantly with greater odds of sigmoidoscopy (OAR = 2.72, 95% CI (1.18 – 6.25) P 

(OAR = 2.11, 95% CI (1.17 – 3.80) P =0.01), compared with no coverage. 

• African American (vs. white) adults (OAR = 0.17, 95% CI (0.05 – 0.52), P < 0.001) an

education (OAR = 0.40, 95% CI (0.21 – 0.73), P < 0.001) were significantly less likely colonoscopy. 

• No physician recommendation and other perceived barriers to screening contributed t

screening among county health center and private physician office participants. 

• Results of multivariate logistic regression models describing screening barriers assoc

screening among users of private physician offices 

• CHC patients less frequently cited no physician recommendation as a barrier to FOBT

no recommendation as a barrier to FS and colonoscopy, compared with PPO patient

KQ3 - Which strategies are effective in increasing the appropriate use of 

NA 

C-142
 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY:	 Authors, ref ID: Messina, CR, et al.38 

Year of publication: 2009 Dates of data collection: October 2004 – January 2005 (Group 1), April 2004 – July 200Trial name: NA 

colorectal cancer screening and followup? KQ4 - What are the current and NA projected capacities to deliver colorectal cancer screening and surveillance at the population level? KQ5 - What are the effective approaches NA for monitoring the use and quality of colorectal cancer screening? QUALITY RATING: Fair 

C-143
 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

Quality Assessment-Internal Validity for Observational Studies 

Yes No Other (CD, NR, NA) 

C-144
 

Were the groups similar at baseline regarding the most X important prognostic indicators? Were the drop-out or response rates acceptable (≤ 20%)? [If X – The response rates were 47% for private phy

between 20% and 60%, check other and explain.] participants and 52% for CHC participants, indica

of selection bias. Those who didn’t participate in differ in a significant way from those who did. 

Were the differential drop-out or response rates acceptable (≤ NA 

15%)? Were intervention/exposure measures valid, reliable, and NA equally applied? Were the outcome assessors blinded to the intervention or NA exposure status of subjects? Were outcome measures valid, reliable, and equally applied? Used validated, NHIS survey items and CRC scr

behavior/attitudinal questions piloted prior to this 

Does the analysis control for baseline differences? X Were important potential confounding and modifying X variables taken into account in the design and analysis (e.g., through matching, stratification, or statistical adjustment)? Were the statistical methods used to assess the abstracted X outcomes appropriate? Quality Rating (Good, Fair, or Poor): Fair 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY:	 Authors, ref ID: Muus, K, et al.39 

Year of publication: 2009 Dates of data collection: 2004-2005 Trial name: NA 

OBJECTIVE OR AIM: To describe the prevalence of FOBT testing (and PSA testing for prostate cancer) within t

rurality and to determine whether or not BMI is associated with receipt of FOBT (and PSAand Alaska Native men. 

DESIGN: Setting: National survey of American Indian and Alaska Native men conducted by the Na

Native American Aging Study design: secondary analysis of cross-sectional data Duration (mean followup): NA Overall study size (N enrolled/N analyzed): 2447 

Sample size: N = 2447 Describe intervention: No intervention; survey only RECRUITMENT: Population-based convenience sample recruited through tribal service areas 

(population-based, clinic-based, volunteer, other) INCLUSION CRITERIA: Complete records for all model covariates, self-report of never having been diagnosed wit

prostate cancer) 

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EXCLUSION CRITERIA:	 NR 

POPULATION CHARACTERISTICS:
 

Mean age & range (years): Sex (% female): Race: Other: 

FOBT in Past Year 

Age 

55-64 34% 65-74: 40% ≥75: 27% 

Male: 100% Race: 100% American Indian or Alaska Native Residence Urban: 20% Large rural: 20%
 Small rural: 18% Isolated rural: 43% 

No FOBT in Past Year 

Age 

55-64 42% 65-74: 39% ≥75: 19% Male: 100% Race: 100% American Indian or Alaska Native Residence Urban: 20% Large rural: 17%
 Small rural: 17% Isolated rural: 46% 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY:	 Authors, ref ID: Muus, K, et al.39 

Year of publication: 2009 Dates of data collection: 2004-2005 Trial name: NA 

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Attrition/Drop-out (not available for NA
 endpoint measurement): Adherence:
 Contamination: Response Rates (e.g. for surveys): NR
 STATISTICAL ANALYSES: Describe: 

The authors compared the frequency distributions for all independent variables by screenthe association of FOBT testing by creating a logistic regression model that modeled the lwithin the past year as a functional BMI category and the covariates.
 

ASSESSMENT OF EXPOSURES AND POTENTIAL CONFOUNDERS: 

Covariates were derived from the literature as potential confounders and included in the loCovariates included were: age, marital status, education, limitations in activities of daily livinsurance coverage, and rurality of residence 

OUTCOME ASSESSMENT: Outcome Measures: 

FOBT assessed through the question, “How long has it been since you had your last blookit?” 

RESULTS: KQ2 - What factors influence the use of	 Outcomes: 

colorectal cancer screening? •	 Having an FOBT was associated with higher age (P < .001), being married (

unemployed during the past year(P < .001), having a regular health care prohealth insurance (P < .01), having higher numbers of limitations in activities 

and being a non-smoker (P < .001). 

•	 Prevalence of FOBT use in past year in urban areas did not differ by age. In 

65 and older showed a higher prevalence of recent FOBTs than younger me

•	 Adjusted screening odds ratios for FOBT screening in past year by BMI cate

underweight, BMI < 18.5, as the reference group in logistic regression modewith FOBT screening (data below). 

BMI Category OR Underweight 95% CI 1 -Healthy 1 (0.5, 2.0) Overweight 

1 (0.5, 2.0) Obese I 

1 (0.5, 2.2) Obese II 

0.9 (0.4, 1.9) Obese III 

0.8 (0.3, 1.8) 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY:	 Authors, ref ID: Muus, K, et al.39 

Year of publication: 2009 Dates of data collection: 2004-2005 Trial name: NA 

KQ3 - Which strategies are effective in NA increasing the appropriate use of colorectal cancer screening and followup? KQ4 - What are the current and NA projected capacities to deliver colorectal cancer screening and surveillance at the population level? KQ5 - What are the effective approaches NA for monitoring the use and quality of colorectal cancer screening? QUALITY RATING: Fair 

C-147
 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

Quality Assessment-Internal Validity for Observational Studies 

Yes No Other (CD, NR, NA) 

C-148
 

Were the groups similar at baseline regarding the most NA important prognostic indicators? Were the drop-out or response rates acceptable (≤ 20%)? [If NR – They report that 94 out of 243 regional triba

between 20% and 60%, check other and explain.] areas agree to participate, but they do not report 

the individual participant level 

Were the differential drop-out or response rates acceptable (≤ NR 

15%)? Were intervention/exposure measures valid, reliable, and X equally applied? Were the outcome assessors blinded to the intervention or NR exposure status of subjects? Were outcome measures valid, reliable, and equally applied? X Self-reported of FOBT status in past year is subje

and social desirability bias 

Does the analysis control for baseline differences? NA Were important potential confounding and modifying X variables taken into account in the design and analysis (e.g., through matching, stratification, or statistical adjustment)? Were the statistical methods used to assess the abstracted X outcomes appropriate? Quality Rating (Good, Fair, or Poor): Fair 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

C-149
 

STUDY:	 Authors, ref ID: Nguyen et al.40 

Year of publication: 2008 Dates of data collection: July to October 2004 Trial name: NA 

OBJECTIVE OR AIM: Describe the baseline colorectal screening rates among participants in an on-going interve

increase such screening in Vietnamese Americans aged 50 to 74, identifies factors assoc

recommends educational strategies to increase screening rates in this population. 

DESIGN: Setting: Telephone interview 

Study design: Baseline survey Duration (mean followup): only a one-time call Overall study size (N enrolled/N analyzed): 867 

Sample size: 867 Describe intervention: NA (Telephone survey RECRUITMENT: A cross-sectional sample was drawn from a sampling frame consisting of all individuals in (population-based, clinic-based, directories with Vietnamese surnames previously used in a number of Vietnamese Americvolunteer, other) INCLUSION CRITERIA:	 1) self-identified as Vietnamese or Vietnamese American, 2) aged 50 to 74, 3) lived in Ala

Counties, California or Harris County, Texas, and intended to stay in this study area for 2 either English or Vietnamese. 

EXCLUSION CRITERIA:	 Anyone not fitting inclusion criteria and those who already completed interviews. POPULATION CHARACTERISTICS:	 Sample Mean age & range (years): Range: 50-74 [29% 50-54; 22% 55-59; 22% 60-64; 27% 65-74] 

Sex (% female): 47% Race: 100% Vietnamese or Vietnamese American 

Sample 

Attrition/Drop-out (not available for The remaining call attempts reached 1,044 eligible respondents, of which 894 agreed to cendpoint measurement): response rate of 86%. Adherence: Contamination: Response Rates (e.g. for surveys): 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY:	 Authors, ref ID: Nguyen et al.40 

Year of publication: 2008 Dates of data collection: July to October 2004 Trial name: NA 

STATISTICAL ANALYSES: Describe: 

Frequency distributions were tabulated for demographics, health care characteristics, kno

colorectal screening rates. Multiple logistic regression models were developed to identify fsuch screening. The demographics, healthcare characteristics, and knowledge and attitudindependent variables in the models because these variables were found to be associated utilization among Vietnamese Americans in previous studies 

ASSESSMENT OF EXPOSURES AND NR POTENTIAL CONFOUNDERS: OUTCOME ASSESSMENT: Outcome Measures:
 

The dependent variables were colorectal cancer screening test 1) recognition, 2) receipt, intention. 

RESULTS: 

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KQ2 - What factors influence the use of colorectal cancer screening? 

Outcomes: 

•	 Factors positively associated with ever having been screened were being in the o

years), residing in California, having private or public insurance, having a regular personal doctor, having heard of colon polyps, worrying about colon cancer, thincancer, thinking need FOBT and sigmoidoscopy/colonoscopy even if feel healthysigmoidoscopy/colonoscopy preparation troublesome. All significant. 

•	 Factors negatively associated included having annual household income less tha

employed, having a Vietnamese doctor, and thinking sigmoidoscopy/colonoscop

•	 In general, the rates of colorectal screening recognition, receipt, currency, and in

ever had: FOBT, 20% Sigmoidoscopy, 26% Colonoscopy, 62% any test 

•	 25% were up-to-date on FOBT, 16% were up-to-date on FS, and 23% were up-to

KQ3 - Which strategies are effective in Outcomes: NA increasing the appropriate use of colorectal cancer screening and followup? KQ4 - What are the current and Outcomes: NA projected capacities to deliver colorectal cancer screening and surveillance at the population level? KQ5 - What are the effective approaches Outcomes: NA for monitoring the use and quality of colorectal cancer screening? QUALITY RATING: Fair 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

Quality Assessment-Internal Validity for Observational Studies 

Yes No Other (CD, NR, 

C-151
 

Were the groups similar at baseline regarding the most important prognostic NA 

indicators? Were the drop-out or response rates acceptable (≤ 20%)? [If between 20% X 

and 60%, check other and explain.] Were the differential drop-out or response rates acceptable (≤ 15%)? NA 

Were intervention/exposure measures valid, reliable, and equally applied? NA Were the outcome assessors blinded to the intervention or exposure status NA 

of subjects? Were outcome measures valid, reliable, and equally applied? X Does the analysis control for baseline differences? X Were important potential confounding and modifying variables taken into X account in the design and analysis (e.g., through matching, stratification, or statistical adjustment)? Were the statistical methods used to assess the abstracted outcomes X appropriate? Quality Rating (Good, Fair, or Poor): Fair Reviewer #1 initials: BLM Reviewer #2 initials: DJH Comments (explain poor quality ratings): 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

C-152
 

STUDY:	 Authors, ref ID: O'Malley et al.41 

Year of publication: 2002 Dates of data collection: January 2000 - March 2000 Trial name: NA 

OBJECTIVE OR AIM: Examine the effects of primary care, health insurance, and HMO participation on adheren

cervical, and colorectal cancer screening 

DESIGN: Setting: low income communities in DC 

Study design: RDD and targeted telephone survey Duration (mean follow-up): NA Overall study size (N enrolled/N analyzed): 1205 in sample 

Sample size: 1205 Describe intervention: NA RECRUITMENT: List of telephone numbers to obtain a 25% RDD (from phone exchanges in low income ce(population-based, clinic-based, targeted listed households volunteer, other) INCLUSION CRITERIA:	 female, over 40 years, residing in DC in low income areas 

EXCLUSION CRITERIA: POPULATION CHARACTERISTICS:
 

Mean age & range (years): 64.8 years (16.3% 41-49 years) Sex (% female): 100% Race: 82.7% Black Other: 26.5% living as married 

84.8% had a regular doctor 13.2% uninsured 

Attrition/Drop-out (not available for NA 

endpoint measurement): Adherence:
 Contamination: Response Rates (e.g. for surveys): 85% STATISTICAL ANALYSES: Describe: 

chi-square and log reg 

ASSESSMENT OF EXPOSURES AND Age, household income, race/ethnicity, education, work status, marital status, family size, 

POTENTIAL CONFOUNDERS: knowledge/ attitudes and beliefs, insurance status and plan type, features of primary care 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY:	 Authors, ref ID: O'Malley et al.41 

Year of publication: 2002 Dates of data collection: January 2000 - March 2000 Trial name: NA 

C-153
 

relationship 

OUTCOME ASSESSMENT: Outcome Measures:
 

adherence to FOBT use-- for this, 990 is the sample size since that's only women 52 and allow those 50-52 time to get one) 

RESULTS: KQ2 - What factors influence the use of Outcomes: colorectal cancer screening? factors statistically significant with self-reported FOBT in the past 2 years (P < 0.01): 

no regular site of care or regular clinician going to a provider that provides less comprehensive care reported low levels of compassion, trust or communication in the physician/pt relationship all insurance levels 

KQ3 - Which strategies are effective in Outcomes: NA increasing the appropriate use of colorectal cancer screening and followup? KQ4 - What are the current and Outcomes: NA projected capacities to deliver colorectal cancer screening and surveillance at the population level? KQ5 - What are the effective approaches Outcomes: NA for monitoring the use and quality of colorectal cancer screening? QUALITY RATING: Fair 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

Quality Assessment-Internal Validity for Observational Studies 

Yes No Other (CD, NR, 

Were the groups similar at baseline regarding the most important prognostic N/A indicators? Were the drop-out or response rates acceptable (≤ 20%)? [If between 20% X 85% response r

and 60%, check other and explain.] Were the differential drop-out or response rates acceptable (≤ 15%)? N/A Were intervention/exposure measures valid, reliable, and equally applied? N/A Were the outcome assessors blinded to the intervention or exposure status NR 

of subjects? Were outcome measures valid, reliable, and equally applied? some were used 

unclear which acontrol for confo

Does the analysis control for baseline differences? X Were important potential confounding and modifying variables taken into 

X 

account in the design and analysis (e.g., through matching, stratification, or statistical adjustment)? Were the statistical methods used to assess the abstracted outcomes 

X 

appropriate?

C-154
 

Quality Rating (Good, Fair, or Poor): Fair Reviewer #1 initials: DJH Reviewer #2 initials: LCM Comments (explain poor quality ratings): 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY:	 Authors, ref ID: O’Malley AS et al.42 

Year of publication: 2005 Dates of data collection: Used the year 2000 Medicare Current Beneficiary Survey (MCTrial name: NA 

OBJECTIVE OR AIM: To (1) quantify the size of any racial differences in the receipt of CRC screening among M

the extent to which racial differences were confounded by socioeconomic status (SES); (2

of the health care system, in addition to having a usual health care provider, were associarates; and (3) ascertain whether these features differed for socioeconomic and racial grou

DESIGN: Setting: Population-based, Medicare part A and B beneficiaries with a usual physician 

Study design: Cross-sectional Duration (mean followup): NA Overall study size (N enrolled/N analyzed): N=9985 

Sample size: N=9985 Describe intervention: NA RECRUITMENT: Population-based from the 2000 Medicare enrollment file (population-based, clinic-based, volunteer, other) INCLUSION CRITERIA:	 • Medicare part A and B beneficiaries 

• Having a usual physician 

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EXCLUSION CRITERIA:	 • Racial groups other than “black” or “white” 

• Persons who were institutionalized 

• < 65 years 

• End-stage renal disease • Not having a usual physician • Persons with a prior diagnosis of CRC • Persons with gastrointestinal symptoms • Persons with large amounts of missing data 

POPULATION CHARACTERISTICS: Mean age & range (years) 

65-74 ≥75 

Sex (% female): Race/ethnicity 

White Black 

Other: 

Frequency (N=11,154) 

4492 6662 6518 

10,133 

1021 

Weighted 

44.9 (055.1 (058.6 (091.7 (0

8.2 (0.
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY:	 Authors, ref ID: O’Malley AS et al.42 

Year of publication: 2005 Dates of data collection: Used the year 2000 Medicare Current Beneficiary Survey (MCTrial name: NA 

Health status 

Excellent–very good Good Fair-poor 

Education 

≥High school diploma No high school diploma 

Income 

>50 000 20 001-50 000 ≤20 000 

Additional insurance 

Private Medigap policy Medicaid (dual eligible) No other insurance 

4592 3704 2828 7423 3731 1205 4618 5320 7257 

993 

2618 

42.1 (033.3 (024.5 (068.5 (031.5 (010.8 (041.4 (047.7 (067.7 (0

8.2 (0.

24.1 (0

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 Attrition/Drop-out (not available for NA endpoint measurement): Adherence: NA 

Contamination: NA Response Rates (e.g. for surveys): 84% 

STATISTICAL ANALYSES: Describe: Univariate, bivariate, and stratified analyses were performed, including assess

Logistic regression models were then built. First, race (with age and sex) was entered into beneficiary characteristics were added, followed by the health system characteristics. A h

constructed to assess whether there was any significant clustering of MCBS respondents Sampling weights accounting for the multistage sample design and non-response were usestimates with SAS callable SUDAAN 

ASSESSMENT OF EXPOSURES AND Exposure: 

POTENTIAL CONFOUNDERS: Self-reported receipt of recent CRC screening (a home fecal occult blood test had been p

months, a flexible sigmoidoscopy was received in the past 5 years, or a colonoscopy was years) Independent Variables: Beneficiary 

• Race • SES (income and education) 

Health care financing 

• Insurance 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY:	 Authors, ref ID: O’Malley AS et al.42 

Year of publication: 2005 Dates of data collection: Used the year 2000 Medicare Current Beneficiary Survey (MCTrial name: NA Delivery system 

• Physician specialty • Perceived quality of care 

• Availability of specialists, • HMO status 

Confounders 

• Age •

Sex 

• Attitudes toward health care 

• Health status • Rural V urban residence 

• Awareness of CRC • Frequency of physician out-patient visits 

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OUTCOME ASSESSMENT: Outcome Measures: 

Factors which influence the self-reported receipt of recent CRC screening including: 

• Home fecal occult blood test had been performed in the past 12 months 

• Flexible sigmoidoscopy was received in the past 5 years, • Colonoscopy was performed in the past 5 years 

KQ2 – What factors influence the use of colorectal cancer screening? Race 

• White • Black 

Age, y 

• ≥75 

• 65-74 

Sex 

• Female • Male 

Education 

Summary: Unadjusted rates of screening were 48.2% (95% CI 46.4-50.0) for white and 39black beneficiaries (P < 0.001). Racial differences in CRC screening receipt were eliminated after adjustment for socioecoby income and education. SES remained significant after adjusting for other personal and Outcomes: Adjusted odds of receiving CRC screening: OR (95% CI) 1.00 (0.82-1.16) 1.0 (Reference) 0.86 (0.79-0.93) 1.0 (Reference) 0.87 (0.79-0.97) 1.0 (Reference) 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY:	 Authors, ref ID: O’Malley AS et al.42 

Year of publication: 2005 Dates of data collection: Used the year 2000 Medicare Current Beneficiary Survey (MCTrial name: NA 

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•	 College degree or higher 

•	 Some college 

• High school/vocational 

diploma 1 

•	 No high school diploma 

Income (annual household), $ 

•	 >50 000 •	 20 001-50 000 1. •	 <20 000 

Urban (vs rural reference group) Supplementary insurance 

• Medicaid 

•	 Private supplementary policy 

•	 No supplementary insurance 

Aware of colorectal cancer Attitudes toward health care 

• More favorable 

• Less favorable 

Health status 

• Excellent–very good 

• Good 

• Fair-poor 

Outpatient physician visits in past year (excludes ED visits) 

• ≥4 

• ≤3 

Information giving by usual physician 

•	 



Higher rating 

• Lower rating (poorer) 

1.79 (1.55-2.07) 1.51 (1.30-1.76) 1.23 (1.12-1.36) 1.0 (Reference) 1.53 (1.27-1.85) 1.30 (1.17-1.45) 1.0 (Reference) 1.12 (0.97-1.31) 0.87 (0.70-1.09) 1.23 (1.07-1.42) 1.0 (Reference) 2.76 (2.29-3.33) 1.23 (1.14-1.33) 1.0 (Reference) 0.98 (0.87-1.12) 1.08 (0.95-1.24) 1.0 (Reference) 1.47 (1.31-1.64) 1.0 (Reference) 1.12 (1.00-1.25) 1.0 (Reference) 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY:	 Authors, ref ID: O’Malley AS et al.42 

Year of publication: 2005 Dates of data collection: Used the year 2000 Medicare Current Beneficiary Survey (MCTrial name: NA 

Usual physician type 

•	 Primary care generalist 

•	 Specialty other than primary 

care 

HMO (vs fee for service) Availability of specialists 

•	 Higher rating • Lower rating 

1.31 (1.12-1.53) 1.0 (Reference) 1.56 (1.34-1.82) 1.32 (1.16-1.50) 1.0 (Reference) 

KQ3 – Which strategies are effective in NA increasing the appropriate use of colorectal cancer screening and followup? 

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KQ4 – What are the current and NA projected capacities to deliver colorectal cancer screening and surveillance at the population level? KQ5 – What are the effective NA approaches for monitoring the use and quality of colorectal cancer screening? QUALITY RATING: Fair 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

Quality Assessment-Internal Validity for Observational Studies 

Yes No Other (CD, NR, N

Were the groups similar at baseline regarding the most important prognostic NR indicators? Were the drop-out or response rates acceptable (≤ 20%)? [If between 20% and X 60%, check other and explain.] Were the differential drop-out or response rates acceptable (≤ 15%)? NA 

Were intervention/exposure measures valid, reliable, and equally applied? NA Were the outcome assessors blinded to the intervention or exposure status of NR 

subjects? Were outcome measures valid, reliable, and equally applied? X Does the analysis control for baseline differences? X Were important potential confounding and modifying variables taken into account in X the design and analysis (e.g., through matching, stratification, or statistical adjustment)? Were the statistical methods used to assess the abstracted outcomes appropriate? X 

Quality Rating (Good, Fair, or Poor): Fair 

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Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

C-161
 

STUDY: Colorectal Authors, ref ID: Peterson, et al.43 cancer screening Year of publication: 2007 

among men and Dates of data collection: 2000 NHIS 

women in the United Trial name: NA 

States OBJECTIVE OR AIM: To explore gender differences in use of CRC screening tests and gender-specific correlates of CRC testing 

DESIGN: Setting: United States 

Study design: Cross-sectional Duration (mean followup): no f/u data reported Overall study size (N enrolled/N analyzed): 32,374 survey, 11,487 met criteria for this study 

Sample size: 11,487 Describe intervention: RECRUITMENT: Population based, national household survey
 

(population-based, clinic-based, The 2000 supplement (e.g., Cancer Control Module) was administered to 32,374 adults >= 18 years of age; revolunteer, other) INCLUSION Men and women >= 50 years of age without a prior diagnosis of CRC were considered eligible for analysis of CRITERIA: EXCLUSION CRITERIA:
 POPULATION CHARACTERISTICS Women (n=6705) (stratified by sex): Men (n=4782) 

% (95% CI) % (95% CI) 

Age 50–64 59.6 (57.8–61.4) 

53.9 

(52.5–55.3) 

65–74 24 (22.5–25.4) 

24.7 

(23.6–25.8) 

75 + 16.5 (15.3–17.7) 

21.4 

(20.3–22.6) 

Race Non-Hispanic white 81.7 (80.4–83.0) 81.7 (80.6–82.9) 

Non-Hispanic black 8.1 (7.2–9.2) 9.4 (8.6–10.3) 

Hispanic 6.8 (6.1–7.7) 6.6 (6.0–7.3) Non-Hispanic other 3.3 (2.7–4.1) 2.3 (1.8–2.8) 

Education Less than high school 23.3 (22.0–24.7) 23 (21.6–24.3) 

High school diploma 27.8 (26.3–29.3) 36.9 (35.4–38.3) 

Some college, no degree 15.7 (14.5–16.8) 16 (15.0–17.0) 

College degree or higher 33.3 (31.6–34.9) 24.2 (22.9–25.5) 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

C-162
 

STUDY: Colorectal cancer screening among men and women in the United 

Authors, ref ID: Peterson, et al.43 

Year of publication: 2007 Dates of data collection: 2000 NHIS Trial name: NA 

States 

Family income <=$20,000 >$20,000 Insurance 

19.8 

80.2 

(18.6–21.2) 

(78.9–81.4) 

30 70 

(28.7–31.3) (68.7–71.3) 

Private Public None Reported functional limitation Reported usual source of care Reported family history of CRC 

77.9 

15 

7.1 

42.2 

91.8 

7.8 

(76.5–79.2) 

(13.9–16.2) (6.3–8.1) 

(40.5–43.9) 

(90.9–92.6) (6.9–8.7) 

73.7 19.5 

6.9 

55 

94.8 

8.3 

(72.4–74.9) (18.4–20.6) (6.2–7.6) 

(53.5–56.4) 

(94.1–95.4) 

(7.6–9.0) 

Attrition/Drop-out (not available for endpoint measurement): Adherence: 

NA 

Contamination: Response Rates (e.g. for surveys): 

As above, response rate 72% for NHIS 

STATISTICAL • Bivariate analysis to characterize factors associated with CRC screening by gender using Wald 

ANALYSES: tailed P values ≤0.05 were considered statistically significant 

•	 Separate multivariable logistic regression models for each gender to explore the relationship bet

and factors of interest 

•	 The Survey Data Analysis computer package was used to calculate variance estimations •	 To reflect U.S. population estimates and adjust for nonresponse, the results were weighted usin

ASSESSMENT OF Sociodemographic factors included age, gender, ethnicity/ race, education, annual income, and insurance typ

EXPOSURES AND 50–64, 65–74, and >=75. Race/ethnicity categories were non- Hispanic white, Non-Hispanic black, Hispanic, a

POTENTIAL was categorized as less than high school, high school diploma, some college but no degree, and college degr

CONFOUNDERS: group for income (<$20,000 vs. >=$20,000). Insurance type was considered private if respondents reported h

military plan, CHAMPUS, or Tricare. Public insurance included Medicaid, Medicare without private supplemenor other public assistance, such as a state-sponsored plan. Persons who reported no insurance type or single as having none. Considered the presence of self-reported functional limitation, having a usual place to receive 

degree family history of CRC, and receipt of other preventive care (influenza vaccine in the last year, pneumocurrent mammography in the last 2 years, Pap smear in the last 3 years, and for men, prostate-specific antigeyears). 

OUTCOME Participants asked if they ever had a sigmoidoscopy, colonoscopy, or proctoscopy. If they answered affirmativ
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

C-163
 

STUDY: Colorectal Authors, ref ID: Peterson, et al.43 cancer screening Year of publication: 2007 

among men and Dates of data collection: 2000 NHIS 

women in the United Trial name: NA 

States ASSESSMENT: which test they had received (sigmoidoscopy, colonoscopy, proctoscopy, or something else) and were read de

necessary. Subjects who responded positively that they had previously undergone a screening test were asked when the

Persons who reported that they had never undergone the test or who had not had the test recently (sigmoidoslast 10 years or FOBT in the last year) were asked to provide the main reason (no reason, did not need it, docput it off, too expensive, too painful, had another examination, no doctor, other). Subjects who had not had rec

asked if a doctor or other health professional had recommended a screening test in the past year. 

Results KQ2 - What factors influence the use of Adjusted Odds Ratios and 95 % CI Predicting Current CRC Testing Among Men and Women colorectal cancer screening? 

All 

Men Wom

Gender OR (95% CI) OR (95% CI) OR (95

Male 1 — NA NA NA NA Female 0.98 (0.88–1.08) Age 50–64 1 — 1 — 1 — 65–74 1.78 (1.58–2.01) 1.5 (1.25–1.79) 1.82 (1.75 + 1.4 (1.22–1.61) 1.28 (1.03–1.59) 1.53 (1.Race Non-Hispanic white 1 — 1 — 1 — Non-Hispanic black 0.92 (0.78–1.07) 0.98 (0.73–1.31) 0.79 (0.

Hispanic 0.79 (0.64–0.96) 0.78 (0.58–1.05) 0.75 (0.Non-Hispanic other 0.56 (0.39–0.80) 0.72 (0.45–1.14) 0.52 (0.

Education Less than high school 1 — 1 — 1 — High school diploma 1.41 (1.23–1.62) 1.39 (1.12–1.74) 1.22 (1.

Some college, no degree 1.55 (1.32–1.81) 1.36 (1.06–1.75) 

1.44 

(1.

College degree or higher 2.12 (1.84–2.44) 1.93 (1.54–2.41) 

1.73 

(1.

Family income
 <=$20,000 0.81 (0.71–0.92) 0.86 (0.70–1.06) 

0.93 

(0.

>$20,000 1 — 1 — 1 — Insurance Private 1 — 1 — 1 — Public 0.77 (0.67–0.88) 0.87 (0.69–1.09) 0.79 (0.None 0.51 (0.40–0.64) 0.51 (0.35–0.74) 0.71 (0.Reported functional limitation 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY: Colorectal Authors, ref ID: Peterson, et al.43 cancer screening among men and women in the United 

Year of publication: 2007 Dates of data collection: 2000 NHIS Trial name: NA 

States 

No 1 — 1 — 1 — 

Yes 1.41 (1.27–1.55) 1.42 (1.21–1.67) 1.38 (1.

Reported usual source of care No 0.3 (0.24–0.39) 0.42 (0.28–0.61) 0.47 (0.

Yes 1 — 1 — 1 — 

Reported first-degree family history of CRC No 1 — 1 — 1 — 

Yes 2.08 (1.77–2.43) 1.96 (1.51–2.54) 2.21 (1.

Had mammogram in the last 2 years (women only) No NA NA NA NA 0.25 (0.

Yes 1 — 

Had PSA testing in the last 2 years (men only) No NA NA 0.29 (0.25–0.34) NA NA Yes 1 — 

KQ3 - Which Outcomes: strategies are effective in 

NA 

increasing the appropriate use of colorectal cancer screening and followup? 

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KQ4 - What are the current and projected capacities to deliver colorectal cancer screening and surveillance at the population level? 

Outcomes: NA 

KQ5 - What are the NA effective approaches for monitoring the use and quality of colorectal cancer screening? 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

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STUDY: Colorectal Authors, ref ID: Peterson, et al.43 cancer screening among men and 

Year of publication: 2007 Dates of data collection: 2000 NHIS 

women in the United Trial name: NA 

States QUALITY RATING: Good 

Quality Assessment-Internal Validity for Observational Studies 

Yes No Other (CD

Were the groups similar at baseline regarding the most important prognostic indicators? n/a 

Were the drop-out or response rates acceptable (≤ 20%)? [If between 20% and 60%, check x NHIS RR 

other and explain.] mention o

aged >= 5

Were the differential drop-out or response rates acceptable (≤ 15%)? n/a 

Were intervention/exposure measures valid, reliable, and equally applied? x Were the outcome assessors blinded to the intervention or exposure status of subjects? n/a Were outcome measures valid, reliable, and equally applied? x Self-report

participant

Does the analysis control for baseline differences? x Were important potential confounding and modifying variables taken into account in the x design and analysis (e.g., through matching, stratification, or statistical adjustment)? Were the statistical methods used to assess the abstracted outcomes appropriate? x Quality Rating (Good, Fair, or Poor): Good Reviewer #1 initials: MJG Reviewer #2 initials: DJH Comments (explain poor quality ratings): 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

C-166
 

STUDY:	 Authors, ref ID: Pham HH, et al.44 

Year of publication: 2005 Dates of data collection: 2001 Trial name: NA (secondary analysis of CTS) 

OBJECTIVE OR AIM: To identify characteristics of physicians and their practices that are associated with the qu

their patients receive. 

DESIGN: Setting: National primary care physician survey 

Study design: Cross-sectional, retrospective study Duration (mean follow-up): NA Overall study size (N enrolled/N analyzed): 3,660 physicians, 24, 581 patients 

Sample size: 3,660 physicians, 24, 581 patients Describe intervention: NA (survey) RECRUITMENT: Population-based 

(population-based, clinic-based, Data from Community Tracking Study (CTS)
 volunteer, other) INCLUSION CRITERIA: Primary care delivered by physicians providing usual care for Medicare beneficiaries ≥ 65 EXCLUSION CRITERIA: Cancer diagnosis,ID-9-CM or V codes:153, 154.0, 154.1, V10.05, V10.06
 POPULATION CHARACTERISTICS:
 Mean age & range (years): NR (≥ 65 yrs) Sex (% female): NR Race: Other: 

NA 

Attrition/Drop-out (not available for 

endpoint measurement): Adherence:
 Contamination: Response Rates (e.g. for surveys): STATISTICAL ANALYSES: Individual beneficiaries were the unit of analysis. Each patient was assigned to a single us

physician, but each physician could serve as the usual source of care for multiple beneficpercentages are therefore weighted to represent estimates for the national population of M65 years and older, using CTS survey weights to take into account the complex physician Authors used logistic regression to analyze the association between physician and practicbeneficiary delivery of each of the 6 preventive services. We used SUDAAN software to a
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY:	 Authors, ref ID: Pham HH, et al.44 

Year of publication: 2005 Dates of data collection: 2001 Trial name: NA (secondary analysis of CTS) variances given the complex survey sampling strategy and the clustering of beneficiaries study was approved by the institutional review contractor for Mathematica Inc. P = .05 wa

ASSESSMENT OF EXPOSURES AND NR POTENTIAL CONFOUNDERS: OUTCOME ASSESSMENT: Proportion of eligible beneficiaries receiving each of 6 preventive services: diabetic monito

measurement or eye examinations, screening for colon (colonoscopy/FS) or breast canceinfluenza or pneumococcus (self-report and claims) 

RESULTS: KQ2 - What factors influence the use of colorectal cancer screening? 

Association between CRC screening and physician specialty (patients cared for by family patients cared for by general internists 7.8%, P < 0.001); board certification (board certifiecertified 6.5%, P < 0.05); and site of medical school graduation (US or Canada 9.3% vs. nP < 0.05). No statistically significant association between CRC screening among patients cared for bpractice types (e.g., medium/large group vs. solo/two-person group: AOR, 1.12 [95% CI, 0

Patients cared for by physicians with access to reminders were not more likely to have bereminders vs. 5.9% without reminders (adjusted AOR, 0.96 [95% CI, 0.84-1.09]) 

C-167
 KQ3 - Which strategies are effective in NA 

increasing the appropriate use of colorectal cancer screening and followup? KQ4 - What are the current and NA projected capacities to deliver colorectal cancer screening and surveillance at the population level? KQ5 - What are the effective approaches NA for monitoring the use and quality of colorectal cancer screening? QUALITY RATING: Fair 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

Quality Assessment-Internal Validity for Observational Studies Were the groups similar at baseline regarding the most important prognostic indicators? 

Yes No Other (CD, NR, N

CD 

Were the drop-out or response rates acceptable (≤ 20%)? [If between 20% and 60%, check other NA 

and explain.] Were the differential drop-out or response rates acceptable (≤ 15%)? NA 

Were intervention/exposure measures valid, reliable, and equally applied? NR Were the outcome assessors blinded to the intervention or exposure status of subjects? X 

Were outcome measures valid, reliable, and equally applied? X Does the analysis control for baseline differences? X Were important potential confounding and modifying variables taken into account in the design and analysis (e.g., through matching, stratification, or statistical adjustment)? Were the statistical methods used to assess the abstracted outcomes appropriate? X 

Quality Rating (Good, Fair, or Poor): Fair 

C-168
 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY:	 Authors, ref ID: Rosen, A.B., Schneider, E.C.45 

Year of publication: 2004 Dates of data collection: 1999 Trial name: NA 

OBJECTIVE OR AIM: To evaluate whether there is an association between body mass index (BMI) and rates of 

screening. To examine whether BMI-related disparities in colorectal cancer screening diffewomen. 

DESIGN: Setting: National telephone survey 

Study design: Cross-sectional, Secondary data analysis Duration (mean follow-up): No follow-up, one-time data collection Overall study size (N enrolled/N analyzed): 52,886 respondents 

Sample size: Normal Weight Overweight Obese Mo

Sample size: 19,826 Sample size: 21,285 Sample size: 8,315 Sam

Describe intervention: 

No intervention, No intervention, responded No intervention, No responded to BRFFS to BRFFS responded to BRFFS BR

RECRUITMENT: Population-based, BRFFS (population-based, clinic-based, volunteer, other) INCLUSION CRITERIA: Age 50 to 80 

C-169
 

EXCLUSION CRITERIA: 

Did not know, or refused, to report their CRC screening status, did not report height or we

than 80 

POPULATION CHARACTERISTICS: Mean age & range (years): Sex (% female): Race: 

Normal Weight Age range: 50-80 Age: 53.5% 50-64, 32.1% 65-74, 14.5% 75+ Sex: 61.8% female Race: 83.3% White (nonHispanic), 5.9% Black (non-Hispanic), 6.7% Hispanic, 4.2% other 

Overweight Age range: 50-80 Age: 58.4% 50-64, 30.6% 65-74, 11% 75+ Sex: 44.7% female Race: 80.2% White (nonHispanic), 8.5% Black (non-Hispanic), 8.7% Hispanic, 2.7% other 

Obese Age range: 50-80 Age: 78% 50-64, 9.9% 65­74, 10% 75+ Sex: 50.6% female Race: 78% White (nonHispanic), 9.9% Black (non-Hispanic), 10% Hispanic, 2.2% other 

Attrition/Drop-out (not available for endpoint measurement): Adherence: 

NA 

Contamination: Response Rates (e.g. for surveys): Median response rate = 68.4% 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY:	 Authors, ref ID: Rosen, A.B., Schneider, E.C.45 

Year of publication: 2004 Dates of data collection: 1999 Trial name: NA 

STATISTICAL ANALYSES: Describe: 

•	 Respondents were stratified based on BMI and tabulated the characteristics 

•	 Association between BMI and CRC screening using multiple logistic regress

confounders was assessed 

•	 Examined the results for trends and then separately compared each overwe

corresponding group with normal BMI 

ASSESSMENT OF EXPOSURES AND • Examined several factors thought to be potential confounders of the relation

POTENTIAL CONFOUNDERS: screening 

•	 Sociodemographic factors included age, gender, ethnicity, education, marita

census region 

•	 Other variables examined as potential confounders included self-reported he

status, time since last check-up, and lack of insurance coverage for any part 

OUTCOME ASSESSMENT: Outcome Measures: 

•	 Classified an individual as having had colorectal cancer screening if he or sh

either FOBT within the last year or endoscopic screening within the last 5 ye

•	 Each respondent’s BMI was calculated as weight in kilograms divided by he

Results KQ2 - What factors influence the use of Outcomes: colorectal cancer screening? • The rate of screening for morbidly obese respondents was 39.5%, significan

obese (45.0%), overweight (44.3%), or normal weight (43.5%) groups. 

• Those who were less than 65 years of age (P < 0.0001), female (P = 0.0018

not high school graduates (P < 0.0001), widowed, divorced, or separated (P (P < .0001), were uninsured for part or all of the past year (P < .0001), curre

and those respondents whose last checkups were over 1 year ago (P < .000screened than their counterparts. 

• Respondents who reported fair or poor health status were more likely to be s

• Residents of the Northeast were significantly more likely and residents of the 

less likely to be screened than others (data NR) 

• Morbidly obese females were less likely than females with a normal body ma

screening (AOR, -5.6; 95% CI, -2.6 to -8.5). 

• There were no obesity-related disparities in screening rates for males. 

KQ3 - Which strategies are effective in increasing the appropriate use of colorectal cancer screening and followup? 

Outcomes: NA 

KQ4 - What are the current and Outcomes: 

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Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY: Authors, ref ID: Rosen, A.B., Schneider, E.C.45 

Year of publication: 2004 Dates of data collection: 1999 Trial name: NA 

projected capacities to deliver colorectal cancer screening and surveillance at the population level? 

NA 

KQ5 - What are the effective approaches for monitoring the use and quality of colorectal cancer screening? 

Outcomes: NA 

QUALITY RATING: Fair 

Quality Assessment-Internal Validity for Observational Studies 

Yes No Other (CD, NR, 

Were the groups similar at baseline regarding the most important prognostic X Some character

indicators? between the we

as age, sex, and 

Were the drop-out or response rates acceptable (≤ 20%)? [If between 20% 69% response r

and 60%, check other and explain.] by phone Were the differential drop-out or response rates acceptable (≤ 15%)? NR 

Were intervention/exposure measures valid, reliable, and equally applied? NA Were the outcome assessors blinded to the intervention or exposure status NA 

of subjects? Were outcome measures valid, reliable, and equally applied? X Does the analysis control for baseline differences? X Were important potential confounding and modifying variables taken into X account in the design and analysis (e.g., through matching, stratification, or statistical adjustment)? Were the statistical methods used to assess the abstracted outcomes X appropriate? 

C-171
 

Quality Rating (Good, Fair, or Poor): Fair Reviewer #1 initials: BLM Reviewer #2 initials: DJH Comments (explain poor quality ratings): 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

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STUDY:	 Authors, ref ID: Schenck AP, Klabunde CN, Davis WW46 

Year of publication: 2006 Dates of data collection: 2001 Trial name: NA 

OBJECTIVE OR AIM: In an attempt to increase understanding of predictors of CRC test use and the role of race

test use among African Americans and whites enrolled in the Medicare program was initia

DESIGN: Setting: Telephone survey 

Study design: Observational cross-sectional study 

Duration (mean followup): No follow-up, one-year date collection Overall study size (N enrolled/N analyzed): 1,321 White; 580 African American 

All 

Sample size: Sample size: 1,321 White; 580 

African American 

Describe intervention: Intervention: Telephone survey 

designed to assess baseline consumer knowledge, awareness, and use of CRC test 

RECRUITMENT: Population-based, telephone survey
 

(population-based, clinic-based, volunteer, other) INCLUSION CRITERIA:	 Age 50-80, no history of CRC 

EXCLUSION CRITERIA:	 No personal history of CRC POPULATION CHARACTERISTICS: Whites African Americans 

Age: 8.46% age 50-64, 65.23% age Age: 15.02% age 50-64, 60.9% age 

Mean age & range (years): Sex (% female): Race: 

65-74, 26.31% age 75-80 Sex: 55.58% Female 

65-74, 24.08% age 75-80 Sex: 60.61% Female 

Other: 

All 

Attrition/Drop-out (not available for endpoint measurement): Adherence: Contamination: Response Rates (e.g. for surveys): Cooperation rate = 69% STATISTICAL ANALYSES: Describe: 

• A series of nested multivariate logistic regression analyses were conducted 

association of race by category of CRC test use. 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY:	 Authors, ref ID: Schenck AP, Klabunde CN, Davis WW46 

Year of publication: 2006 Dates of data collection: 2001 Trial name: NA 

• Unadjusted models were constructed using a single predictor variable for Af

with white race. 

ASSESSMENT OF EXPOSURES AND POTENTIAL CONFOUNDERS: 

Additional questions assessed respondents’ awareness that CRC risk increases with agerisk for the disease, and their perceived susceptibility to colorectal cancer. Access to medthrough two survey questions asking whether the respondent had a primary care providerphysician for a checkup in the past 12 months. Respondents’ history of CRC and chronic assessed in the survey. CRC risk status was determined by three factors: physician counswas at high risk for colorectal cancer, a family member with colorectal cancer, or a history Additional demographic information, obtained from the Medicare Enrollment Database, incgender, and eligibility for Medicaid, which was used as a proxy for low income. 

OUTCOME ASSESSMENT: Outcome Measures: 

•	 Colorectal cancer test use was determined by describing each test (FOBT, s

colonoscopy) and asking four questions about each test. The questions werdescribed, had you ever heard of it?”; “Have you ever had (this test)?”; “Wherecent (test)?”; and, “Why did you have your most recent (test)?” 

•	 CRC test use was classified into three categories: no CRC test use, some C

with Medicare testing intervals, and current with testing. Respondents were with testing if they had had any of the CRC tests at Medicare covered intervpast year, sigmoidoscopy within the past 4 years, colonoscopy within the paenema within the past 10 years. 

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RESULTS: KQ2 - What factors influence the use of colorectal cancer screening? 

Outcomes: 

•	 Unadjusted analyses showed that African Americans were significantly less 

according to Medicare-covered intervals (OR=0.57, 95% CI 0.46–0.71). Howsociodemographic characteristics, healthcare access, and CRC risk status, statistically significant (OR=0.82, 95%, CI 0.63–1.06). 

•	 Among those not tested according to Medicare-covered intervals, African Am

have been tested at all compared with whites. This difference remained signsociodemographic characteristics, healthcare access, and CRC risk status (0.70). 

•	 African Americans were significantly more likely than whites to have been te

procedure than by FOBT (OR=3.06, 95% CI=1.70 –5.51). 

•	 The strongest predictors identified with adherence to Medicare-covered test

CRC risk (OR=3.82, 95% CI=2.79 –5.23), having a checkup in the past year 

4.44), and having a usual source of care (OR=2.27, 95% CI=1.10–4.69) 

•	 White race and several health services use variables were strong predictors 

compared to having none. Medicare consumers with a usual source of care 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY:	 Authors, ref ID: Schenck AP, Klabunde CN, Davis WW46 

Year of publication: 2006 Dates of data collection: 2001 Trial name: NA 

C-174
 

26.91) and those with a checkup in the last year (OR=2.16, 95% CI=1.27–3.to have had some CRC tests. 

KQ3 - Which strategies are effective in NA increasing the appropriate use of colorectal cancer screening and followup? KQ4 - What are the current and NA projected capacities to deliver colorectal cancer screening and surveillance at the population level? KQ5 - What are the effective approaches NA for monitoring the use and quality of colorectal cancer screening? QUALITY RATING: Fair Quality Assessment-Internal Validity for Observational Studies 

Yes No Other (CD, NR, N

Were the groups similar at baseline regarding the most important prognostic X Age difference p<

indicators? p<0.0001 Were the drop-out or response rates acceptable (≤ 20%)? [If between 20% and X 69% cooperation 

60%, check other and explain.] Were the differential drop-out or response rates acceptable (≤ 15%)?	 NA 

Were intervention/exposure measures valid, reliable, and equally applied? X Were the outcome assessors blinded to the intervention or exposure status of NA 

subjects? Were outcome measures valid, reliable, and equally applied?	 X 

Does the analysis control for baseline differences? X 

Were important potential confounding and modifying variables taken into account in X the design and analysis (e.g., through matching, stratification, or statistical adjustment)? Were the statistical methods used to assess the abstracted outcomes appropriate? X 

Quality Rating (Good, Fair, or Poor): Fair 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

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STUDY:	 Authors, ref ID: Schneider, E.C., Rosenthal, M., Gatsonis, C.G., Zheng, J., Epstein, A.M

Year of publication: 2008 Dates of data collection: 2000 Trial name: NA 

OBJECTIVE OR AIM: The authors assessed whether beneficiaries in MMC plans were more likely than those in 

to receive colorectal cancer (CRC) screening and whether type of insurance was associatscreening strategies. 

DESIGN: Setting: In-person survey 

Study design: Cross-sectional, retrospective secondary data analysis Duration (mean follow-up): No follow-up, 2000 survey data Overall study size (N enrolled/N analyzed): 10,173 

Sample size: MMC FFS Supplemental FFS No S

Sample size: 10,173 Sample size: 2,219 Sample si

Describe intervention: No intervention, answered No intervention, answered Medicare No interve

Medicare Current Beneficiary Current Beneficiary Survey Current BeSurvey 

RECRUITMENT: Medicare population-based (population-based, clinic-based, volunteer, other) INCLUSION CRITERIA:	 Age 65+, Medicare beneficiary, non-institutionalized EXCLUSION CRITERIA: Institutionalized, from 11 states (and

MMC enrollees, age 65 and youngerAmerican, or Hispanic, and respond

 Puerto Rico) that had no MMC plan opt

, part-year enrollees in MMC, responde

ents who reported a personal history of CRC 

ion, from 12 s

nts who were 

POPULATION CHARACTERISTICS: MMC FFS Supplemental FFS No S

Age: 26.1% 65-69, 27.5% 70-74, Age: 21.6% 65-69, 28.3% 70-74, Age: 28.2

Mean age & range (years): 22.4% 75-79, 24% 80+ 24.3% 75-79, 25.7% 80+ 20.4% 75

Sex (% female): Race: 

Sex: 58.7% female Race: 90.6% White, 9.4% Black 

Sex: 58% female Race: 95.8% White, 4.2% Black 

Sex: 59.3Race: 79

Other: 

Overall 

Attrition/Drop-out (not available for endpoint measurement): Adherence: Contamination: Response Rates (e.g. for surveys): Response rate was 84.3% 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY:	 Authors, ref ID: Schneider, E.C., Rosenthal, M., Gatsonis, C.G., Zheng, J., Epstein, A.M

Year of publication: 2008 Dates of data collection: 2000 Trial name: NA 

STATISTICAL ANALYSES: Describe: 

•	 The authors calculated the weighted percentage of beneficiaries with each o

and other characteristics of interest overall and for each insurance group. 

•	 Using the definitions of CRC screening, they calculated, for each insurance 

percentage of beneficiaries that reported CRC screening strategies. 

•	 They compared percentages of beneficiaries who had received CRC screen

pairing of the insurance groups using a chi-square test or a t test as appropr

•	 To address potential “selection biases” they used a propensity score model 

nonrandom distribution of beneficiaries among insurance types. 

•	 To calculate propensity scores, they constructed a multinomial logistic regre

all of the patient characteristics that could plausibly predict whether or not an enroll in managed care. 

C-176
 

ASSESSMENT OF EXPOSURES AND Variables examined: POTENTIAL CONFOUNDERS: • Demographics (age, gender, race, Hispanic origin, education, unmarried) 

•	 Access (SES, insurance type) 

• Health status 

•	 Care-seeking variables (worry about health, avoid going to a MD, keep to se

soon as feel bad, had a problem and didn't visit a MD, same MD for >5 yr) 

•	 Area of residence (non-metro area resident) 

OUTCOME ASSESSMENT: Outcome Measures: 

CRC screening status and type of test received 

RESULTS: KQ2 - What factors influence the use of Outcomes: colorectal cancer screening? • Beneficiaries who were age 80 or older, women, black, Hispanic, and who h

attainment and lower income were less likely to receive screening (data not 

• Beneficiaries were less likely to receive interval-appropriate screening (FOB

screening in past 5 yrs.) if they reported that they avoided going to the physkept to themselves when sick (47.3% vs. 53.4%), failed to visit a physician a(55.6% vs. 48.7%), or had a problem and didn’t visit the physician (44.6% vs

• Worrying about health more than others was not associated with receiving a 

the same physician for 5 years, except for having an invasive screening withvs. 37.3%, P < 0.024). 

• MMC (52.9%) was more likely than supplemental insurance groups (FFS SU

receive CRC screening, but time-interval appropriateness was similar betweintervals provided) 

• Beneficiaries in MMC were more likely than those In the FFS SUPP group to 

appropriate FOBT (36.3% vs. 32.1%; P = 0.013), but less likely to receive a
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY:	 Authors, ref ID: Schneider, E.C., Rosenthal, M., Gatsonis, C.G., Zheng, J., Epstein, A.M

Year of publication: 2008 Dates of data collection: 2000 Trial name: NA 

invasive screening procedure (35.9% vs. 40.8%; P < 0.001) 

KQ3 - Which strategies are effective in Outcomes: 

increasing the appropriate use of NA
 colorectal cancer screening and
 followup?
 KQ4 - What are the current and Outcomes: projected capacities to deliver NA
 colorectal cancer screening and
 surveillance at the population level? KQ5 - What are the effective approaches Outcomes: for monitoring the use and quality of NA colorectal cancer screening? QUALITY RATING: Fair 

C-177
 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

Quality Assessment-Internal Validity for Observational Studies 

Yes No Other (CD, NR, NA) 

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Were the groups similar at baseline regarding the most important prognostic X The Managed care, FFS, and 

indicators? groups had several large differ

distribution, race, etc. of their p

Were the drop-out or response rates acceptable (≤ 20%)? [If between 20% X 

and 60%, check other and explain.] Were the differential drop-out or response rates acceptable (≤ 15%)? NA 

Were intervention/exposure measures valid, reliable, and equally applied? NA 

Were the outcome assessors blinded to the intervention or exposure status NA of subjects? Were outcome measures valid, reliable, and equally applied? X Does the analysis control for baseline differences? X Were important potential confounding and modifying variables taken into X account in the design and analysis (e.g., through matching, stratification, or statistical adjustment)? Were the statistical methods used to assess the abstracted outcomes X appropriate? Quality Rating (Good, Fair, or Poor): Fair Reviewer #1 initials: BLM Reviewer #2 initials: DJH Comments (explain poor quality ratings): 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

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STUDY:	 Authors, ref ID: Schootman, M., Jeffe, D., Baker, E., Walker, M.48 

Year of publication: 2006 Dates of data collection: 2002 Trial name: NA 

OBJECTIVE OR AIM: To analyze the contextual effect of area poverty rate on never having been screened for b

colorectal cancer by (1) describing the extent of the variation in screening behaviors amonareas; (2) determining if the variation in lack of screening can be explained by differences persons who resided in these areas; and (3) determining if living in a metropolitan area wiincreased the likelihood of never having been screened for cancer over and above individ

DESIGN: Setting: Cities in the United States 

Study design: Secondary data analysis Duration (mean follow-up): No follow-up, data collection for one year Overall study size (N enrolled/N analyzed): 118,000 persons residing in 98 areas 

Sample size: MMSA poverty rate 5.0-9.9 MMSA poverty rate 10.0+ 

Sample size: 59,336 Sample size: 59,301 

Describe intervention: Intervention: None, survey Intervention: None, survey (BRFFS) 

(BRFFS) 

RECRUITMENT: Population-level (population-based, clinic-based, volunteer, other) INCLUSION CRITERIA: Age 50 or older EXCLUSION CRITERIA: NR POPULATION CHARACTERISTICS: MMSA poverty rate 5.0-9.9 MMSA poverty rate 10.0+ 

Age: 17.8% 50-59, 11% 60-69, 13% Age: 17.4% 50-59, 12.2% 60-69, 

Mean age & range (years): Sex (% female): Race: 

70+ Sex: 58.9% Race: 80.8% White, 7.2% African 

14.4% 70+ Sex: 60.4% Race: 73.1% White, 11.1% African 

American, 7.5% Other, 4.6% American, 7.8% Other, 8% Hispanic 

Other: Hispanic Attrition/Drop-out (not available for NR endpoint measurement): Adherence: Contamination: Response Rates (e.g. for surveys): STATISTICAL ANALYSES: Describe: 

The multilevel logistic models reported in this paper were all two level models in which pewithin MMSAs (level 2). The authors used restricted iterative generalized least squares anquasilikelihood estimation in all models.
 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY:	 Authors, ref ID: Schootman, M., Jeffe, D., Baker, E., Walker, M.48 

Year of publication: 2006 Dates of data collection: 2002 Trial name: NA 

ASSESSMENT OF EXPOSURES AND Multilevel logistic models to control for income, education, employment, insurance, race, a

POTENTIAL CONFOUNDERS: health, having trouble getting medical care, and smoking status. OUTCOME ASSESSMENT: Outcome Measures: 

FOBT and sigmoidoscopy/colonoscopy 

RESULTS: KQ2 - What factors influence the use of colorectal cancer screening? 

Outcomes: 

•	 The variation (ICC) between MMSAs varied by screening test: FOBT: 2.7 and co

1.2 (P<0.05). 

•	 The crude odds ratios per 5% increase in MMSA level poverty rate were attenua

individual level factors, but remained associated with never having had an FOBT CI (1.12 – 1.27) 

•	 Adding the individual level factors to the model did not affect the crude odds ratio

MMSA level poverty rate in never having had a colonoscopy. 

•	 For all screening tests, significant MMSA level variance remained after including 

factors, and after adding MMSA level poverty rate (all P<0.05). 

KQ3 - Which strategies are effective in Outcomes: 

increasing the appropriate use of NA
 colorectal cancer screening and
 followup?
 

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KQ4 - What are the current and Outcomes: projected capacities to deliver NA
 colorectal cancer screening and
 surveillance at the population level? KQ5 - What are the effective approaches Outcomes: for monitoring the use and quality of NA colorectal cancer screening? QUALITY RATING: Fair 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

Quality Assessment-Internal Validity for Observational Studies 

Yes No Other (CD, NR, 

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Were the groups similar at baseline regarding the most important prognostic NA 

indicators? Were the drop-out or response rates acceptable (≤ 20%)? [If between 20% NR and 60%, check other and explain.] Were the differential drop-out or response rates acceptable (≤ 15%)? NA 

Were intervention/exposure measures valid, reliable, and equally applied? NA Were the outcome assessors blinded to the intervention or exposure status NA of subjects? Were outcome measures valid, reliable, and equally applied? X Does the analysis control for baseline differences? X Were important potential confounding and modifying variables taken into X account in the design and analysis (e.g., through matching, stratification, or statistical adjustment)? Were the statistical methods used to assess the abstracted outcomes X appropriate? Quality Rating (Good, Fair, or Poor): Fair Reviewer #1 initials: BLM Reviewer #2 initials: DJH Comments (explain poor quality ratings): 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

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STUDY:	 Authors, ref ID: Schumacher, M., Slattery, M., Lanier, A., Ma, K., Edwards, S., Ferucci, 

Year of publication: 2008 Dates of data collection: 2004-2007 Trial name: Education and Research Towards Health (EARTH) Study 

OBJECTIVE OR AIM: The purpose of this study was to examine the prevalence rates for cervical, breast, and co

among American Indian and Alaska Native people living in Alaska and in the Southwest Upredictive factors associated with receiving each of the cancer screening tests. 

DESIGN: Setting: Clinic 

Study design: Cross-sectional Duration (mean followup): One-time data collection Overall study size (N enrolled/N analyzed): 2,779 (participants ≥ 50 yrs with data availacolonoscopy/sigmoidoscopy)/2,745 for whom timing since last procedure was known) 

Sample size: Sample size: 2,745 

Intervention: Participants 

Describe intervention: completed several surveys: Health, 

Lifestyle, and Physical Activity Questionnaire; diet history questionnaire 

RECRUITMENT: Population-based 

(population-based, clinic-based, volunteer, other) INCLUSION CRITERIA:	 Required participants to be American Indian or Alaska Native eligible for Indian Health Se

at least 18 years of age (colonoscopy/sigmoidoscopy analyses were restricted to those agactively undergoing cancer treatment, and physically and mentally able to read and underto complete survey instruments and medical tests 

EXCLUSION CRITERIA:	 Individuals with unknown duration between colonoscopy/sigmoidoscopy POPULATION CHARACTERISTICS: Mean age & range (years): NR Sex (% female): NR Race: 100% American Indian/Alaska native Other: Attrition/Drop-out (not available for NA 

endpoint measurement): Adherence:
 Contamination: 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY:	 Authors, ref ID: Schumacher, M., Slattery, M., Lanier, A., Ma, K., Edwards, S., Ferucci, 

Year of publication: 2008 Dates of data collection: 2004-2007 Trial name: Education and Research Towards Health (EARTH) Study 

Response Rates (e.g. for surveys): STATISTICAL ANALYSES: Describe: 

•	 Prevalence odds ratios and their 95% confidence intervals were calculated using 

regression models. 

•	 Linear tests for trend were done by including the categorical variable as a contin

regression analysis. 

•	 For each of the potential predictors described, they calculated odds ratios and 95

controlling for age and location because age and location most often confounded the predictor and the screening test. 

•	 Multivariate logistic regression was then done including all variables that were st

related to the screening test (95% confidence limits exclude 1.0) in the analysis clocation. 

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ASSESSMENT OF EXPOSURES AND • For each of the potential predictors described, they calculated odds ratios and 95

POTENTIAL CONFOUNDERS: controlling for age and location because age and location most often confounded 

the predictor and the screening test. 

OUTCOME ASSESSMENT: Outcome Measures: 

Analyses classified individuals as having had a colonoscopy/sigmoidoscopy in the past fiv

RESULTS: KQ2 - What factors influence the use of colorectal cancer screening? 

Outco

•

mes: 

Individuals in the age group 60+ were somewhat more likely to have received cosigmoidoscopy in the past five years that those aged 50–59 years. 

• There was a significant difference in the prevalence of screening by location (Ala

Southwest 11.8%). 

• There was an increasing trend in screening with increasing level of education (lin• Individuals with a family history of any cancer were more likely to be screened, a

history of colorectal cancer. Former smokers were more likely to be screened thasmokers; those with other medical conditions were more likely to be screened. 

• Individuals who spoke only English at home versus those who spoke a Native la

with English) were also more likely to be screened, as were those residing in an higher incomes. Women who had received other screening tests (Pap test or malikely to have received a colonoscopy or sigmoidoscopy. 

• Overall screening rate was 22% (n = 604) • Alaska Natives were more likely to have obtained CRC screening than Southwes

3.86; 95% CI, 2.92-5.10) 

KQ3 - Which strategies are effective in Outcomes: 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY:	 Authors, ref ID: Schumacher, M., Slattery, M., Lanier, A., Ma, K., Edwards, S., Ferucci, 

Year of publication: 2008 Dates of data collection: 2004-2007 Trial name: Education and Research Towards Health (EARTH) Study 

increasing the appropriate use of NA colorectal cancer screening and followup? KQ4 - What are the current and Outcomes: 

projected capacities to deliver NA
 colorectal cancer screening and
 surveillance at the population level? KQ5 - What are the effective approaches Outcomes: for monitoring the use and quality of NA colorectal cancer screening? QUALITY RATING: Fair 

C-184
 
C-185
 

Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) Quality Assessment-Internal Validity for Observational Studies 

Yes No Other (CD, NR, 

Were the groups similar at baseline regarding the most important prognostic NA indicators? Were the drop-out or response rates acceptable (≤ 20%)? [If between 20% NR and 60%, check other and explain.] Were the differential drop-out or response rates acceptable (≤ 15%)? NA 

Were intervention/exposure measures valid, reliable, and equally applied? NA Were the outcome assessors blinded to the intervention or exposure status NA of subjects? Were outcome measures valid, reliable, and equally applied? X Does the analysis control for baseline differences? X Were important potential confounding and modifying variables taken into X account in the design and analysis (e.g., through matching, stratification, or statistical adjustment)? Were the statistical methods used to assess the abstracted outcomes X appropriate? Quality Rating (Good, Fair, or Poor): Fair Reviewer #1 initials: BLM Reviewer #2 initials: DJH Comments (explain poor quality ratings): 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

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STUDY:	 Authors, ref ID: Seeff et al.50 

Year of publication: 2004 Dates of data collection: 2000 Trial name: NA 

OBJECTIVE OR AIM: Estimate the most current rates of CRC test use, to evaluate factors previously described 

test use, and to describe first-time national estimates of barriers to CRC testing from the ppublic. 

DESIGN: Setting: In-person interview, National Health Interview Survey (NHIS) 

Study design: Secondary data analysis Duration (mean follow-up): No follow-up, analyzed 2000 data Overall study size (N enrolled/N analyzed): 11,734 responded to FOBT questions, 11,8sigmoidoscopy/colonoscopy/proctoscopy questions All 

Sample size: Sample size: 11,734 responded to FOBT questions, 

11,816 responded to 

Describe intervention: sigmoidoscopy/colonoscopy/proctoscopy questions RECRUITMENT: National Health Interview Survey (NHIS) 

(population-based, clinic-based, volunteer, other) INCLUSION CRITERIA:	 Age 50+ 

EXCLUSION CRITERIA:	 Inadequate responses to questions, history of CRC, or refused or did not know the answe

POPULATION CHARACTERISTICS:	 All 

NR 

Mean age & range (years): 

Sex (% female): Race: Other: 

All 

Attrition/Drop-out (not available for Household response rate was 88.9% endpoint measurement): for the core NHIS survey and 72.1% Adherence: for the Cancer Control Module Contamination: Response Rates (e.g. for surveys): STATISTICAL ANALYSES: Describe: 

•	 Multivariate logistic regression was used to determine the independent varia

of the three endpoints. 

•	 Additional models were designed to determine whether either mammograph
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY:	 Authors, ref ID: Seeff et al.50 

Year of publication: 2004 Dates of data collection: 2000 Trial name: NA 

associated with CRC test use among women. 

•	 Two additional models compared screening test versus no test and nonscre

•	 Variables were included in the multivariate models if they have been previou

CRC screening, if they appeared to be associated with test use based on devaried according to test indication. 

ASSESSMENT OF EXPOSURES AND Variables included: 

POTENTIAL CONFOUNDERS: • Demographic (age, gender, race, Hispanic, education, marital status) 

•	 Access (insurance status, income, usual source of care, MD visits/year) 

•	 Personal/risk factors (general health status, obesity/BMI, history of cancer- p

screening, physical activity, fruit/veggies, smoking, alcohol) 

OUTCOME ASSESSMENT: Outcome Measures: 

FOBT within the previous year, endoscopy (sigmoidoscopy/colonoscopy/proctoscopy) witeither FOBT within the previous year and/or endoscopy within the past 10 years. Secondary outcome: Reasons for Never Undergoing Colorectal Examinations or for Undergoing Tests beyond Interval

C-187
 RESULTS: 

KQ2 - What factors influence the use of colorectal cancer screening? 

Outcomes: 

•	 With regard to FOBT, test rates increased with increasing age until ages 70–

decreased. 

•	 Persons 65+ years old were significantly more likely to report having underg

with persons 50–64 years old. 

•	 White, non-Hispanic, and married persons were more likely to report having 

than Black, Hispanic, or unmarried persons. 

•	 Those who had private health insurance, Medicare, Medi-GAP, or a combina

and Medicare had higher rates of FOBT use than those with other public ins

•	 Having a usual source of care and the frequency with which the respondent 

physician were both associated with higher reported test rates. 

•	 Patterns of associations for endoscopy were similar to those for FOBT use, 

being male was associated with higher rates of endoscopy. 

•	 Those respondents with a personal or family history of cancers other than C

CRC were more likely to report having undergone endoscopy than those wit

•	 Women who underwent a mammogram or Pap smear test within recommen

likely to report having undergone CRC tests compared with those who did n

•	 Persons who exercised regularly reported higher rates of test use for all CRC 

•	 Former cigarette smokers reported higher test rates compared with never-sm
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY:	 Authors, ref ID: Seeff et al.50 

Year of publication: 2004 Dates of data collection: 2000 Trial name: NA 

C-188
 

•	 Between 4–7% of respondents who did not undergo CRC testing had been a

do so. 

•	 MD recommended FOBT (Age 50–64 yrs): 258 (5.9%); 95% CI, (5.1–6.7); M

FOBT (Age 50–64 yrs): 4006 (94.1%); 95% CI, (93.3–94.9) 

•	 MD recommended FOBT (Age ≥ 65): 162 (4.1%); 95% CI, (3.4–4.9); MD did 

(Age ≥ 65): 3838 (95.9%); 95% CI, (95.1–96.6) 

•	 MD recommended Endoscopy (Age 50–64 yrs): 255 (7.2%); 95% CI, (6.3–8

Endoscopy (Age 50–64 yrs): 3318 (92.8%); 95% CI, (91.9–93.7) 

•	 MD recommended Endoscopy (Age 50–64 yrs): 135 (4.8%); 95% CI, (3.9–5

FOBT (Age 50–64 yrs): 2907; (95.2%); 95% CI, (94.4–96.1) 

KQ3 - Which strategies are effective in Outcomes: 

increasing the appropriate use of NA colorectal cancer screening and followup? KQ4 - What are the current and Outcomes: projected capacities to deliver NA colorectal cancer screening and
 surveillance at the population level? KQ5 - What are the effective approaches Outcomes: for monitoring the use and quality of NA colorectal cancer screening? QUALITY RATING: Fair 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

Quality Assessment-Internal Validity for Observational Studies 

Yes No Other (CD, NR, 

C-189
 

Were the groups similar at baseline regarding the most important prognostic indicators? 

N/A 

Were the drop-out or response rates acceptable (≤ 20%)? [If between 20% and 60%, check other and explain.] 

Household respfor the core NHIfor the Cancer CModule 

Were the differential drop-out or response rates acceptable (≤ 15%)? N/A Were intervention/exposure measures valid, reliable, and equally applied? N/A Were the outcome assessors blinded to the intervention or exposure status of subjects? 

N/A 

Were outcome measures valid, reliable, and equally applied? X The procedures 

those who askedintroduce some 

Does the analysis control for baseline differences? X Were important potential confounding and modifying variables taken into account in the design and analysis (e.g., through matching, stratification, or statistical adjustment)? 

X 

Were the statistical methods used to assess the abstracted outcomes X appropriate? Quality Rating (Good, Fair, or Poor): Fair Reviewer #1 initials: BLM Reviewer #2 initials: DJH Comments (explain poor quality ratings): 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

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STUDY:	 Authors, ref ID: Shah, M, Zhu, K., Potter, J.51 

Year of publication: 2006 Dates of data collection: 2000 Trial name: National Health Interview Survey 

OBJECTIVE OR AIM: This study aimed to examine whether low acculturation is a risk factor for the underutilizat

screening examinations in the Hispanic population. 

DESIGN: Setting: US 

Study design: Survey study; secondary data analysis Duration (mean followup): One-time data collection, no follow-up Overall study size (N enrolled/N analyzed): 1163 

All 

Sample size: Sample size: 1163 

Intervention: None; National 

Describe intervention: Health Interview Survey (NHIS) RECRUITMENT: Population-based (population-based, clinic-based, volunteer, other) INCLUSION CRITERIA: Hispanic men and women between the age of 50 and 80 years who identified themselves 

were diagnosed with colon or rectal cancer 

EXCLUSION CRITERIA:	 Respondents that underwent any of tests for diagnostic purposes were excluded from the 

POPULATION CHARACTERISTICS: Low Acculturation Moderate Acculturation H

Sex: 58.9% female Sex: 54.9% female Sex: 55.3

Mean age & range (years): Age: 38.8% 50-59, 33.6% 60-69, Age: 47.1% 50-59, 32.1% 60-69, Age: 50.6Sex (% female): 27.5% 70-80 20.8% 70-70 18.7% 70

Race: Race: Hispanic Race: Hispanic Race: His

Other: 

All 

Attrition/Drop-out (not available for The total household response rate endpoint measurement): was approximately 88.9% and the Adherence: final response rate for the Adult Core Contamination: component was 72.1%. Response Rates (e.g. for surveys): 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY:	 Authors, ref ID: Shah, M, Zhu, K., Potter, J.51 

Year of publication: 2006 Dates of data collection: 2000 Trial name: National Health Interview Survey 

STATISTICAL ANALYSES: Describe: 

•	 Chi-square tests were executed to assess differences in colorectal cancer s

levels of acculturation and to evaluate statistical significance among the cros

•	 With the use of multiple logistic regression, odds ratios having a screening p

for each acculturation level. 

•	 The analysis was repeated for each of the outcomes: having a FOBT, or an 

•	 Odds ratios and 95% confidence intervals were adjusted for demographic fa

age, education, marital status, family income, and ratio of family income to p

•	 Other variables that were included in the logistic regression model were sele

the use of either FOBT in the past year or an endoscopy in the past 5 years levels. 

•	 Logistic regression analyses were also performed separately for men and w

ASSESSMENT OF EXPOSURES AND Cross-tabulations were performed to assess relationships among potential confounding vaPOTENTIAL CONFOUNDERS: variables. 

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OUTCOME ASSESSMENT: Outcome Measures:
 

The use of at-home FOBT in the past year, any endoscopy procedures in the past 5 yearsthe outcomes of the study.
 

RESULTS: KQ2 - What factors influence the use of colorectal cancer screening? 

Outcomes: 

•	 Higher acculturated Hispanics were significantly less likely to not have an en

years or not have either an FOBT in the past year or endoscopy in the past variables were adjusted for in addition to sociodemographic variables, the coodds ratio estimates for both moderate and high acculturation included the nrelations appeared (Endoscopy: OR = 0.77; 95% CI (0.49–1.20); p=0.040; F

•	 After adjusting for sociodemographic variables and other factors, the confide

ratio for males included the null for no endoscopy and no FOBT and for eitheHispanic women, there was no association for any of the three screening va95% CI (0.19–1.58) p=0.046; Female: OR = 0.54; 95% CI (0.22–1.31) p=0.1

•	 Adjusted rates for not being screening with low English language usage as t

AOR, 0.92; 95% CI, 0.60-1.42; High: AOR, 0.75; 95% CI, 0.45-1.25 

KQ3 - Which strategies are effective in Outcomes: 

increasing the appropriate use of NA colorectal cancer screening and
 followup?
 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY:	 Authors, ref ID: Shah, M, Zhu, K., Potter, J.51 

Year of publication: 2006 Dates of data collection: 2000 Trial name: National Health Interview Survey 

KQ4 - What are the current and Outcomes: 

projected capacities to deliver NA colorectal cancer screening and
 surveillance at the population level?
 KQ5 - What are the effective approaches Outcomes: for monitoring the use and quality of NA colorectal cancer screening? QUALITY RATING: Fair 

C-192
 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

Quality Assessment-Internal Validity for Observational Studies 

Yes No Other (CD, NR, NA) 

C-193
 

Were the groups similar at baseline regarding the most important prognostic X Higher acculturated individua

indicators? characteristics than other groWere the drop-out or response rates acceptable (≤ 20%)? [If between 20% The total household respons

and 60%, check other and explain.] approximately 88.9% and the 

the Adult Core component w

Were the differential drop-out or response rates acceptable (≤ 15%)? NA 

Were intervention/exposure measures valid, reliable, and equally applied? NA Were the outcome assessors blinded to the intervention or exposure status NA 

of subjects? Were outcome measures valid, reliable, and equally applied? X Does the analysis control for baseline differences? X Were important potential confounding and modifying variables taken into X account in the design and analysis (e.g., through matching, stratification, or statistical adjustment)? Were the statistical methods used to assess the abstracted outcomes X appropriate? Quality Rating (Good, Fair, or Poor): Fair Reviewer #1 initials: BLM Reviewer #2 initials: DR Comments (explain poor quality ratings): 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

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STUDY:	 Authors, ref ID: Shapiro et al.52 

Year of publication: 2008 Dates of data collection: 2005 Trial name: NA 

OBJECTIVE OR AIM: The purpose of this analysis was to determine the prevalence of colorectal cancer test use 

various factors and to examine reasons for not having a colorectal cancer test. 

DESIGN: Setting: USA 

Study design: Secondary data analysis Duration (mean follow-up): No follow-up Overall study size (N enrolled/N analyzed): 30,873 All 

Sample size: Sample size: 13,480 people > 50 

No Intervention 

Describe intervention: RECRUITMENT: Population-based; National Health Interview Survey
 

(population-based, clinic-based, volunteer, other) INCLUSION CRITERIA:	 Respondents ages 50+, no family history of colorectal cancer or certain other risk factors 

EXCLUSION CRITERIA:	 Respondents with a personal history of colorectal cancer or missing information on history POPULATION CHARACTERISTICS:	 All 

NR 

Mean age & range (years): 

Sex (% female): Race: Other: 

All 

Attrition/Drop-out (not available for NA endpoint measurement): Adherence: Contamination: Response Rates (e.g. for surveys): STATISTICAL ANALYSES: Describe: 

To provide national estimates of the prevalence of colorectal cancer test use, responses wprobability of selection with adjustments for nonresponse and poststratification. Adjusted percentages (predictive margins) were computed from multiple logistic regressioof the variables in Table 2 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY: Authors, ref ID: Shapiro et al.52 

Year of publication: 2008 Dates of data collection: 2005 Trial name: NA 

ASSESSMENT OF EXPOSURES AND NR POTENTIAL CONFOUNDERS: OUTCOME ASSESSMENT: Outcome Measures: 

Rates of CRC screening: FOBT within one year, or endoscopy within 10 years. Secondary Outcome: Reasons for not having a FOBT or endoscopy, by colorectal cancer testing history, NHIS 

RESULTS: KQ2 - What factors influence the use of Outcomes: colorectal cancer screening? • For respondents who reported an endoscopy within the past 10 years, 72.8% 

that their most recent endoscopy was part of a routine exam, whereas 24.3% that they had the endoscopy because of a problem. 

• Among respondents who reported a FOBT within the past year, 91.0% (95% 

their most recent FOBT was part of a routine exam, whereas 7.8% (95% CI, the FOBT because of a problem. 

• Among those respondents who had not had a FOBT or endoscopy within the 

interval, the most commonly reported reason for not having a colorectal canabout it’’. Reasons for not having a FOBT and reasons for not having an end

• Significant factors to receiving any CRC screening test are: education (P < .

income (P < .0006), marital status (P = .01), health care coverage (P < .000

care (P < .0001), general health status (P < .0001), personal history of nonc.0001), physical activity (P < .0001), cigarette smoking (P < .0001), and alco

• Large effect sizes for SES variables and for factors related to healthcare acc

regular doctor) 

• Yes, doctor recommended FOBT/Endoscopy to respondents that never had 

CI, (3.1- 4.4); and never had Endoscopy: 435; %, 10.3; 95% CI, (9.3-11.5); recommend FOBT/Endoscopy to respondents that never had FOBT: 4,347; 96.9); and never had Endoscopy: 4,091; %, 89.7; 95% CI, (88.5-90.7); Yes, 

FOBT/Endoscopy to respondents that had FOBT but not within the recomme95% CI, (4.0- 5.3); Yes, doctor recommended FOBT/Endoscopy to respondebut not within the recommended time: 635; %, 12.1; 95% CI, (11.1-13.1); Norecommend FOBT/Endoscopy to respondents that had FOBT but not within 5,362; %, 95.4; 95% CI, (94.7-96.0) 

C-195
 

KQ3 - Which strategies are effective in Outcomes: increasing the appropriate use of Black and white about same; Latino much lower colorectal cancer screening and followup?
 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY: Authors, ref ID: Shapiro et al.52 

Year of publication: 2008 Dates of data collection: 2005 Trial name: NA 

KQ4 - What are the current and Outcomes: projected capacities to deliver colorectal cancer screening and surveillance at the population level? 

NA 

KQ5 - What are the effective approaches for monitoring the use and quality of colorectal cancer screening? 

Outcomes: NA 

QUALITY RATING: Good 

Quality Assessment-Internal Validity for Observational Studies 

Yes No Other (CD, NR, 

Were the groups similar at baseline regarding the most important prognostic 

X 

indicators? Were the drop-out or response rates acceptable (≤ 20%)? [If between 20% N/A and 60%, check other and explain.] Were the differential drop-out or response rates acceptable (≤ 15%)? N/A Were intervention/exposure measures valid, reliable, and equally applied? N/A Were the outcome assessors blinded to the intervention or exposure status N/A of subjects? Were outcome measures valid, reliable, and equally applied? X Does the analysis control for baseline differences? X Were important potential confounding and modifying variables taken into X account in the design and analysis (e.g., through matching, stratification, or statistical adjustment)? Were the statistical methods used to assess the abstracted outcomes X appropriate? 

C-196
 

Quality Rating (Good, Fair, or Poor): Good Reviewer #1 initials: BLM Reviewer #2 initials: RPH Comments (explain poor quality ratings): 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY:	 Authors, ref ID: Shih, YT, Zhao, L, Elting, L53 

Year of publication: 2006 Dates of data collection: 2000 and 2003 NHIS data analyzed (secondary data analysis) Trial name: NA 

OBJECTIVE OR AIM: To examine differences in colonoscopy screening rates between 2000 and 2003 among ra

authors are interested in whether Medicare coverage of colonoscopy, beginning July 2001 use adults 65 years and older). 

DESIGN: Setting: Population-based, nationally representative sample (Cancer Control Module 200

Supplement 2003 of the NHIS) Study design: secondary data analysis of cross-sectional data from 2000 and 2003 (comthe two datasets) Duration (mean followup): NA Overall study size (N enrolled/N analyzed): 2000, N = 6,180; 2003, N = 5,759 

2000 2003 

Sample size: N = 6,180 N = 5,759 

Describe intervention: NA NA 

C-197
 

RECRUITMENT: NHIS recruitment strategy not reported (population-based, clinic-based, volunteer, other) INCLUSION CRITERIA:	 Civilian, noninstitutionalized U.S. households for NHIS; current analysis restricted to particEXCLUSION CRITERIA:	 NR 

POPULATION CHARACTERISTICS:
 

Mean age & range (years): Sex (% female): Race: Other: 


 
 

2000 

• Age (years) 

65-74: 54.62% 75-85: 36.53% 85+: 8.85% 

• Female: 57.46% • Race/ethnicity 

Hispanic: 5.85% Non-Hispanic white: 83.85% Non-Hispanic black: 8.17% Non-Hispanic other: 2.13% 

• Highest education 

attained <HS: 31.57% 

2003 

• Age (years) 

65-74: 52.83% 75-85: 36.37% 85+: 10.80% 

• Female: 57.67% • Race/ethnicity 

Hispanic: 5.89%NonHispanic white: 83.41% Non-Hispanic black: 8.21% Non-Hispanic other: 2.49% 

• Highest education 

attained <HS: 27.66% 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY:	 Authors, ref ID: Shih, YT, Zhao, L, Elting, L53 

Year of publication: 2006 Dates of data collection: 2000 and 2003 NHIS data analyzed (secondary data analysis) Trial name: NA 

HS: 34.02% 

Some college: 19.18% ≥ College: 15.23% 

•	 Income 

Poor: 28.03% Low income: 13.44% Middle income: 8.13% Upper income: 15.53% Unknown: 34.87% 

HS: 34.54% 

Some college: 20.94% ≥ College: 16.86% 

•	 Income 

Poor: 24.09% Low income: 14.69% Middle income: 8.27% Upper income: 16.39% Unknown: 36.57% 

Attrition/Drop-out (not available for NA (secondary data) 

endpoint measurement): Adherence:
 Contamination: Response Rates (e.g. for surveys): 

C-198
 STATISTICAL ANALYSES: Wald chi-squareWald chi-square statistics were used to compare the differences in CRC s

the 2000 and 2003 samples for the identified racial/ethnic groups. Multivariate logistic regression used to examine differences in the likelihood of screening a

ASSESSMENT OF EXPOSURES AND POTENTIAL CONFOUNDERS: 

Potential confounders identified in the literature were controlled for in the multivariate anaVariables: 

• Age 

• Income • Education • Marital status • Census region • Secondary insurance •	 Self-perceived health status 

• History of cancer 

•	 Usual source of care 

OUTCOME ASSESSMENT: Outcome Measures: 

Ever screened by colonoscopy: NHIS survey question, “Have you EVER HAD a sigmoidoproctoscopy?” If the respondent answered yes, they considered that respondent screened

RESULTS: KQ2 - What factors influence the use of • In 2000 blacks were less likely to have had endoscopic CRC screening com
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY:	 Authors, ref ID: Shih, YT, Zhao, L, Elting, L53 

Year of publication: 2006 Dates of data collection: 2000 and 2003 NHIS data analyzed (secondary data analysis) Trial name: NA 

C-199
 

colorectal cancer screening?	 0.788, 95% CI, 0.630, 0.984). However, the odds of screening increased in 

between the two groups were no longer significant (OR = 0.909, 95% CI, 0.7

•	 The odds of screening declined for Hispanics between the two study years (

differences between Hispanics and non-Hispanic whites was not significant significant in 2003 (95% CI, 0.592, 0.997 (P = .048). 

•	 No statistically significant differences were found between non-Hispanic whi

others in either year. 

•	 Sex differences were not significant in 2000, but were in 2003 (OR = , 95% C

•	 Having a history of cancer was not significantly associated with screening in 

significant in 2003 (OR = 1.627, 95% CI, 1.021, 2.591), (P = .041). 

•	 The positive effect of having a usual source of care was significant in 2000 a

more pronounced over time (OR = 4.68, 1 95% CI, 3.092, 7.085) 

•	 Unadjusted screening rates were approximately 30% among Hispanics in 20

increase by 2003. Screening among non-Hispanic whites was approximately to 50% in 2003 (findings presented only in a bar chart) 

•	 . Odds of screening declined for Hispanics between 2000 and 2003 and the 

Hispanics and non-Hispanic whites became significant in 2003 (AOR; 0.77; P = 0.048). 

KQ3 - Which strategies are effective in NA increasing the appropriate use of colorectal cancer screening and followup? KQ4 - What are the current and NA projected capacities to deliver colorectal cancer screening and surveillance at the population level? KQ5 - What are the effective approaches NA for monitoring the use and quality of colorectal cancer screening? QUALITY RATING: Fair 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

Quality Assessment-Internal Validity for Observational Studies 

Yes No Other (CD, NR, N

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Were the groups similar at baseline regarding the most important prognostic X 

indicators? Were the drop-out or response rates acceptable (≤ 20%)? [If between 20% and NR 

60%, check other and explain.] Were the differential drop-out or response rates acceptable (≤ 15%)? NA 

Were intervention/exposure measures valid, reliable, and equally applied? X NHIS data Were the outcome assessors blinded to the intervention or exposure status of NR 

subjects? Were outcome measures valid, reliable, and equally applied? X They used NHIS s

screening variable diagnostic and sc

Does the analysis control for baseline differences? NA Were important potential confounding and modifying variables taken into account in X the design and analysis (e.g., through matching, stratification, or statistical adjustment)? Were the statistical methods used to assess the abstracted outcomes appropriate? X 

Quality Rating (Good, Fair, or Poor): Fair 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

C-201
 

STUDY:	 Authors, ref ID: Shih, Y.T, Elting, L.S, Levin, B.54 

Year of publication: 2008 Dates of data collection: 2000 Trial name: NA 

OBJECTIVE OR AIM: Examine the disparities in colorectal cancer (CRC) screening between US- and foreign-bo

factors associated with such disparities 

DESIGN: Setting: data from 2000 National Health Interview Survey Cancer Control Module 

Study design: Cross-sectional retrospective Duration (mean follow-up): No follow-up Overall study size (N enrolled/N analyzed): 12,179 US-Born Foreign-Born 

Sample size: Sample size: 10,739 Sample size: 1,440 

Survey gathered information on CRC screening rates Survey gathered information o

Describe intervention: RECRUITMENT: Data from 2000 National Health Interview Survey Cancer Control Module
 

(population-based, clinic-based, volunteer, other) INCLUSION CRITERIA:	 Men and women aged 40 years and over in 2000 were asked questions related to CRC sc

EXCLUSION CRITERIA:	 NR POPULATION CHARACTERISTICS:	 US-Born Foreign-Born 

Age: 49.41% 50-64, 35.72% 65-79, 14.87% 80+ Age: 52.18% 50-64, 35.13% 65

Mean age & range (years): Sex: 57.75% Female Sex: 56.10% Female 

Sex (% female): Race/ethnicity: 2.73% Hispanic, 86.42% Non-Hispanic Race/ethnicity: 37.14% Hispan

Race: White, 9.63% Non-Hispanic African American/Black, African American/Black, 15.47

1.22% Non-Hispanic other 

Other: 

Sample 

Attrition/Drop-out (not available for A cancer control module in the 2000 NHIS received a household response rate of 72.1%. endpoint measurement): Adherence: Contamination: Response Rates (e.g. for surveys): STATISTICAL ANALYSES: Describe: 

•	 Descriptive statistics were first presented to depict the differences in demograph

characteristics between the US- and foreign-born groups. Differences were compstatistics for categorical variables and t tests for continuous variables. The authoweighting procedures to account for the complex sample design of the NHIS usincommands in STATA® 7.0 statistical software. 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY:	 Authors, ref ID: Shih, Y.T, Elting, L.S, Levin, B.54 

Year of publication: 2008 Dates of data collection: 2000 Trial name: NA 

•	 Controlling for factors associated with CRC screening in the literature, they mode

likelihood of CRC screening between the US-born and foreign- born groups usinregression. 

•	 The authors then added terms that interact the binary variable indicating foreign-

demographic, socioeconomic, or access barrier variables that were shown to diffUS- and foreign-born groups in their univariate analysis and conducted additionaanalyses. 

ASSESSMENT OF EXPOSURES AND NR --- multivariate logistic models POTENTIAL CONFOUNDERS: OUTCOME ASSESSMENT: Outcome Measures: 

•	 The module included the following 7 sections: Hispanic acculturation, diet and nu

tobacco use, cancer screening, genetic testing, and family history. 

•	 The cancer screening section for adults included skin examinations, Pap smears

breast examinations, prostate specific antigen tests, and CRC screening using eand/or FOBT. 

C-202
 RESULTS: KQ2 - What factors influence the use of Outcomes: 

colorectal cancer screening? • The foreign-born group had a significantly lower rate of CRC screening than US-

54.9%, P < 0.001). 

• Long-time, foreign-born residents of the United States were significantly less like

born non-Hispanic whites (OR, 0.58; 95% CI, 0.51-0.67). 

• Among the foreign-born group, the recent immigrants (defined as people who mi

within the last 10 years) (OR= 0.46, 95% CI, 0.29-0.71, P = 0.0001) were signific

CRC screening than those who had a long residency (15 years or more) (OR = 00.0001) in the United States. 

• Among the US-born individuals, lower rates of CRC screening were found in non

Americans/Blacks (OR=.77, 95% CI, 0.68-0.88, p<.0001) and Hispanics (OR=.65

0.0001). 

• Men were significantly less likely to be screened as were poorer respondents (O

P = 0.01). 

• Factors found to be positively associated with CRC screening were older age; hi

being insured; married; living in the West census region (vs Northeast); being in condition (vs in excellent health); and having a usual source of care. 

• Comparisons of ORs indicated that every foreign-born racial/ethnic subgroup had 

born counterpart 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY:	 Authors, ref ID: Shih, Y.T, Elting, L.S, Levin, B.54 

Year of publication: 2008 Dates of data collection: 2000 Trial name: NA 

KQ3 - Which strategies are effective in Outcomes: 

increasing the appropriate use of
 colorectal cancer screening and NA
 followup?
 KQ4 - What are the current and Outcomes: projected capacities to deliver colorectal cancer screening and NA
 surveillance at the population level?
 KQ5 - What are the effective approaches Outcomes: for monitoring the use and quality of colorectal cancer screening? NA QUALITY RATING: Good 

C-203
 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

Quality Assessment-Internal Validity for Observational Studies 

Yes No Other (CD, NR, NA) 

Were the groups similar at baseline regarding the most important prognostic N/A The US-born and F

indicators? similar except for Race/Were the drop-out or response rates acceptable (≤ 20%)? [If between 20% and A cancer control modul

60%, check other and explain.] X received a household re

Were the differential drop-out or response rates acceptable (≤ 15%)? NR Were intervention/exposure measures valid, reliable, and equally applied? NA 

Were the outcome assessors blinded to the intervention or exposure status of NA 

subjects? Were outcome measures valid, reliable, and equally applied? X Does the analysis control for baseline differences? X Were important potential confounding and modifying variables taken into account X in the design and analysis (e.g., through matching, stratification, or statistical adjustment)? Were the statistical methods used to assess the abstracted outcomes X appropriate? Quality Rating (Good, Fair, or Poor): Good Reviewer #1 initials: BLM) Reviewer #2 initials: DR Comments (explain poor quality ratings): 

C-204
 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

C-205
 

STUDY: Authors, ref ID: Sun, W., Basch, C., Wolf, R., Li, X.55 

Year of publication: 2004 Dates of data collection: December 1, 1999 to March 15, 2000 Trial name: NA 

OBJECTIVE OR AIM: To investigate factors associated with receipt of colorectal cancer (CRC) screening among 

Americans 

DESIGN: Setting: Senior centers 

Study design: Cross-sectional Duration (mean follow-up): No follow-up Overall study size (N enrolled/N analyzed): 203 

Sample size: Describe intervention: 

All 

Sample size: 203 I ntervention: None, survey 

RECRUITMENT: (population-based, clinic-based, volunteer, other) 

Population-based; community centers 

INCLUSION CRITERIA: Age 50+, current New York City resident, free from symptoms of bowel disease EXCLUSION CRITERIA: NR POPULATION CHARACTERISTICS: Mean age & range (years): Sex (% female): Race: Other: 

All 

Age: 22.2% 50-59, 39.4% 60-69, 37.4% 70+ Sex: 43.8% female Race: 100% Asian 

Attrition/Drop-out (not available for endpoint measurement): Adherence: Contamination: Response Rates (e.g. for surveys): 

All 

89.4% agreed to participate 

STATISTICAL ANALYSES: Describe: 

Chi-squared tests were used to analyze categorical data. Stepwise logistic regression was possible predictors that included age, gender, marital status, ownership of dwelling, citizeeducation, household income, health insurance, employment, family history of CRC, salieefficacy, social influence, efficacy of screening, worries or fears, perceived susceptibility, aanalysis of variance (ANOVA) was used to compare means for measured variables amonFOBT, FOBT plus sigmoidoscopy, or neither. 

ASSESSMENT OF EXPOSURES AND POTENTIAL CONFOUNDERS: 

After excluding confounding factors, senior Chinese who had fewer years of residency, lowfears, and higher levels of perceived susceptibility to CRC tended to have higher rates of 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

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STUDY: Authors, ref ID: Sun, W., Basch, C., Wolf, R., Li, X.55 

Year of publication: 2004 Dates of data collection: December 1, 1999 to March 15, 2000 Trial name: NA 

OUTCOME ASSESSMENT: Outcome Measures: 

CRC screening with FOBT or FOBT plus sigmoidoscopy 

RESULTS: KQ2 - What factors influence the use of colorectal cancer screening? 

Outcomes: 

• In multivariate analysis, years of residency in the US (AOR = 0.64, 95% CI, 

worries or fears of positive results (OR = 0.82, P < 0.05), and perceived sus

0.05) were significant predictors of participation in FOBT alone. 

• In addition, years of residency in the US (OR = 0.55, P < 0.01), worries or fe

= 0.66, P < 0.01), and perceived susceptibility participation in FOBT or FOB

• Family history, social influence, efficacy of screening, and intention to scree

independent predictors once the other variables were in the model. 

• For subjects who received both FOBT and sigmoidoscopy, level of educatio

worriers or fears of positive results (OR = 0.72, P < 0.01), and perceived sus

0.01) were significant predictors in multivariate analysis. Family history, self-and intention to screen were no longer independent predictors once the othemodel. 

KQ3 - Which strategies are effective in increasing the appropriate use of colorectal cancer screening and followup? 

Outcomes: 

NA 

KQ4 - What are the current and projected capacities to deliver colorectal cancer screening and surveillance at the population level? 

Outcomes: 

NA 

KQ5 - What are the effective approaches for monitoring the use and quality of colorectal cancer screening? 

Outcomes: 

NA 

QUALITY RATING: Fair 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

Quality Assessment-Internal Validity for Observational Studies 

Yes No 

Were the groups similar at baseline regarding the most important prognostic indicators? 

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Were the drop-out or response rates acceptable (≤ 20%)? [If between 20% and 60%, check other X and explain.] Were the differential drop-out or response rates acceptable (≤ 15%)? 

NA 

Were intervention/exposure measures valid, reliable, and equally applied? 

Were the outcome assessors blinded to the intervention or exposure status of subjects? 

Were outcome measures valid, reliable, and equally applied? X Does the analysis control for baseline differences? X Were important potential confounding and modifying variables taken into account in the design and X analysis (e.g., through matching, stratification, or statistical adjustment)? Were the statistical methods used to assess the abstracted outcomes appropriate? X Quality Rating (Good, Fair, or Poor): Fair Reviewer #1 initials: BLM Reviewer #2 initials: DJH Comments (explain poor quality ratings): 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY: Authors, ref ID: Thompson et al.56-58 

Year of publication: 2002, 2004, 2006 Dates of data collection: baseline: 1998-1999; “final” survey: 2003 Trial name: NR 

OBJECTIVE OR AIM: 2002{#2275): socioeconomic status is explored as a predictor of differences between Hisp

whites in cancer prevention behavior 2004{#1219): to compare CRC screening prevalence and the association between reporteparticipation between Hispanics and non-Hispanic whites 2006{#1188): to examine whether a comprehensive intervention influenced cancer screenpractices in rural communities in Eastern WA state 

DESIGN: Setting: 20 communities in Lower Yakima Valley, Washington State 

Study design: randomization of communities; cross sectional community based surveys 

post-intervention Also, cohort of 823 individuals aged 50 and older who were non-compliant with CRC screagreed to be re-interviewed at final surveying Duration (followup): 30 months of intervention, > 3 years for follow-up survey Overall study size (N enrolled/N analyzed): 

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INTERVENTIONS: No intervention
 Sample size: 10 communities
 Describe intervention: 

Intervention 

10 communities 

Community Advisory Board; Focus groups to develop and test interventions; Activities directed at the community, organizational, small group, and individual levels: Health fairs, block parties, 

festivals and other events where educational presentations were made 

Multiple interventions through 

churches, clinical (free colorectal cancer screening), worksites 

Home health parties Promotoras 

At baseline all 20 comm

in stud
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY: Authors, ref ID: Thompson et al.56-58 

Year of publication: 2002, 2004, 2006 Dates of data collection: baseline: 1998-1999; “final” survey: 2003 Trial name: NR 

RECRUITMENT: (population-based, clinic-based, volunteer, other) 

Recruitment of communities not described 

INCLUSION CRITERIA: Presumed convenience sample of 20 communities that range in size from very small (300

Lower Yakima Valley. For 2004 study, subset of the population-based survey (n = 1795) based on eligibility to aCRC screening (age > =50) 

EXCLUSION CRITERIA: POPULATION CHARACTERISTICS: 2004 2004 2004 CRC study 2004 CRC study Demogr

Baseline Non- Baseline contro

Baseline: Non- Baseline: Hispanic White Hispanic sa

Age (%) 18-39 

Hispanic White 

29 

Hispanic 

63 

40-49 20 1 50-59 34.2 37.2 

50-64 24 11 60-69 25.1 31.4 

65+ 27 8 ≥70 40.7 31.4 

58.0 62.0 

Sex (% female): 57 58 

Race: BreOther population qualities: Education 12.7 76.6 

8th grade or less 

9th-12th, no diploma 

7 

18 

54 23 

52.6 19.4 

16.8 

5.8 

High school or GED 32 13 15.3 <1.0 At least some college 43 11 Insurance Have Insurance: Have Insurance: 

Private 66 24 93.9% 73.0% 

Medicare 11 7 

Public 10 26 

None 1 43 

C-209
 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY: Authors, ref ID: Thompson et al.56-58 

Year of publication: 2002, 2004, 2006 Dates of data collection: baseline: 1998-1999; “final” survey: 2003 Trial name: NR 

Attrition/Drop-out (not available for endpoint measurement): Adherence in control group: Contamination in control group: 

NR 

OUTCOME ASSESSMENT: Outcome Measures: 

For persons > 50 years: FOBT screening within the past 2 years Flex sig/colonoscopy within the past 5 years Categorized as “ever screened, but noncompliant”; “never screened”; “compliant”. For the 2005{#1219) report, when examining the intervention effect, the community pairineffects were controlled for as random effects. To examine whether the interaction effect dnon-Hispanic whites, the authors included an interaction between treatment arm status anRespondents{#1219) who reported having had an FOBT within the past 2 years were clascompliance.” Similarly, if residents ≥ 50 years reported having received a sigmoidoscopy w

they were compliant, but they were not compliant if the sigmoidoscopy was received > 5 yreceived a sigmoidoscopy. In piloting the instrument, they found that their respondents co

sigmoidoscopy from a colonoscopy even when they used a visual of the procedure and deFor that reason, they report sigmoidoscopy/colonoscopy together. 

RESULTS: 

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KQ2 - What factors influence the use of	 Outcomes: 

colorectal cancer screening?	 2002{#2275): 

Non significant differences between Non-Hispanic white and Hispanics in rates of FOBT aadjusted for age, education, and insurance coverage 

 Non Hispanic White Hispanic 

p FOBT ever screened, but noncompliant 54.1 44.1 

FOBT never screened 0.315 

47.5 47.4

 0.986 

FS/Colon screened, but noncompliant 35.1 27.3 0.453 FS/Colon never screened 58.6 63.1 0.458 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY: Authors, ref ID: Thompson et al.56-58 

Year of publication: 2002, 2004, 2006 Dates of data collection: baseline: 1998-1999; “final” survey: 2003 Trial name: NR 

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2004{#1219): Table 2 Participation in FOBT and FS/colon screening, by ethnicity (age unadjusted numbers) 

Non-Hispanic White Hispanic P FOBT ever 55.7 40.6 0.003 In last 2years 34.8 25.8 0.32 

>2 years ago 20.9 9.9 0.005 

FS/colon ever 44.4 26.9 <0.001 In last 5 years 33.7 24.1 <0.05 >5 years ago 10 3.0 0.013 

Table 3 Associations of demographic characteristics with compliance with FOBT and sig/c

 Relative OR (95% CI) of FOBT Relative OR (9

FS/Co

Raw Adjusted Raw 

Race/ethnicity Non-Hispanic white 1.0 1.0 1.0 Hispanic 

0.44 (0.27-0.74) 0.63 (0.33-1.24) 0.63 (0.39-1.01) 0

• adjusted for all other demographic and lifestyle variables 

In 2004{#1219): For being current with FOBT, the OR for Hispanic was lower in raw data (0.44). This differ0.63) when adjusting for age, education, gender and insurance, and became not statisticawide CI, raising question of power to detect difference). For FS/colonoscopy, OR significant in raw (borderline) and actually increased slightly aftefactors. In 2002{#2275): 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY: Authors, ref ID: Thompson et al.56-58 

Year of publication: 2002, 2004, 2006 Dates of data collection: baseline: 1998-1999; “final” survey: 2003 Trial name: NR 

C-212
 

KQ3 - Which strategies are effective in Outcomes: increasing the appropriate use of Final cancer screening practices and cancer prevention lifestyle behaviors of intervention colorectal cancer screening and community pair and community and ethnic-specific baseline proportions of screening servfollowup?
 

A. Community Survey results 

Hispanic 

 Non-His

Intervention Control p Intervention C

FOBT ever screened 48.1 54.2 0.50 57.9 FOBT compliant 70.4 52.8 0.09 48.2 FS/Colon ever screened 29.1 37.5 0.30 44.6 

FS/Colon compliant with screening 83.9 69.7 0.24 77.4 B. Cohort results Final use of screening services for CRC among cohort of respondents ages 50 and older baseline survey

 Hispanic Non-His

Intervention Control p Intervention 

FOBT ever screened , noncompl 78.5 64.0 0.53 62.2 

FOBT never screened 57.1 48.3 0.59 47.4 

FS/Colon ever screened, but noncompl * * 

* * 

FS/Colon never screened 92.6 86.1 0.55 64.8 

KQ4 - What are the current and Outcomes: NA projected capacities to deliver colorectal cancer screening and surveillance at the population level? KQ5 - What are the effective approaches Outcomes: NA for monitoring the use and quality of colorectal cancer screening? QUALITY RATING: KQ2 fair 

KQ3 poor 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

Quality Assessment-Internal Validity for Controlled Trials; note this is for the RCT study 

Yes No Other (CD, NR, 

Was the study described as randomized? x 

C-213
 

Was the method of randomization adequate? X possibly, not d

Was the treatment allocation concealed? Were the groups similar at baseline regarding the most important prognostic indicators? 

X not described

Was the outcome assessor blinded? Was the care provider blinded? Was the patient blinded? Was the drop-out rate acceptable (≤ 20%)? [If between 20% and 60%, 

check other and explain.] Was the differential drop-out rate acceptable (≤ 15%)? 

Were co-interventions avoided or similar? unknown Were outcome measures valid, reliable, and equally applied? x Were all randomized participants analyzed in the group to which they were originally assigned? Quality Rating (Good, Fair, or Poor): KQ 3 poor; KQ 2 fair Reviewer #1 initials: DSP Reviewer #2 initials: DR Comments: 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

C-214
 

STUDY:	 Authors, ref ID: Thorpe, L.E., et al.59 

Year of publication: 2005 Dates of data collection: 2003 Trial name: NA 

OBJECTIVE OR AIM: This detailed analysis of individual- and neighborhood-level factors associated with colon 

will guide the NYC campaign to increase colonoscopy screening and will provide baseline campaign can be evaluated. 

DESIGN: Setting: New York City, NY 

Study design: Secondary data analysis; cross-sectional telephone survey Duration (mean followup): No followup, data collection over 3 months Overall study size (N enrolled/N analyzed): 9,802 (≥50 yrs = 3,606) 

All 

Sample size: Sample size: 3,606 adults 

Intervention: No intervention; New 

Describe intervention: York City Community Health 

Survey (CHS) 

RECRUITMENT: Population-based; New York City Community Health Survey (CHS) (population-based, clinic-based, volunteer, other) INCLUSION CRITERIA: To be surveyed: age 18+ 

In analysis: age 50+ 

EXCLUSION CRITERIA: NR POPULATION CHARACTERISTICS: 

NR 

Mean age & range (years): Sex (% female): Race: Other: Attrition/Drop-out (not available for 

endpoint measurement): Adherence:
 Contamination: Response Rates (e.g. for surveys): Cooperation rate of 59%, response rate of 26%l 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY:	 Authors, ref ID: Thorpe, L.E., et al.59 

Year of publication: 2005 Dates of data collection: 2003 Trial name: NA 

STATISTICAL ANALYSES: Describe: 

•	 Descriptive statistics were used to determine prevalence of screening patterns, a

intervals for both prevalence and affected population estimates were calculated wdistribution. 

•	 Univariate associations were tested at the 0.05 significance level with the chi-squ

analyses were used to examine nonhomogeneity of associations across other co

•	 Multiple logistic regression was used to identify independent predictors of colorec

to adjust for confounding. 

ASSESSMENT OF EXPOSURES AND Multiple logistic regression was used to identify independent predictors of colorectal cance

POTENTIAL CONFOUNDERS: for confounding. Variables included: 

Demographic (age, race, ethnicity, gender) Personal risk behaviors (smoking, physical activity) SES/Access (house income, insurance, regular doctor) Neighborhood/contextual variable (Neighborhood income) 

C-215
 

OUTCOME ASSESSMENT: Outcome Measures:
 

Two models were constructed with different dependent outcomes: having undergone any recommended time frame (every 10 years for colonoscopy, every year for FOBT, and evesigmoidoscopy) and having undergone a colonoscopy within the past 10 years. 

RESULTS: KQ2 - What factors influence the use of Outcomes: colorectal cancer screening? • Adults born outside of the U.S. reported significantly lower levels of any colorecta

adults born in the U.S. 

• Reports of FOBT screening during the preceding year were particularly high amo

women (40%, 95% CI, 35%–45%). 

• Colonoscopy was the most frequently reported screening test in all race and ethn

Hispanic white adults had a significantly higher rate of colonoscopy (and overall other groups. Non-Hispanic black adults reported higher levels of FOBT screeninethnic groups. 

• CRC screening was significantly higher among men aged 65+ years compared w

(63% vs. 52%, OR = 1.3; 95%CI, 1.0 –1.6), whereas differences in overall CRC solder women compared with younger women were more modest (57% vs. 52%; 

• Gender differences in colorectal screening were most evident among Asians, wit

likely as Asian women to have received any timely colorectal cancer screening te95%CI, 1.4–6.3). 

• Current smokers were less likely to have received a timely screening than nonsm

0.62; 95% CI, 0.50–0.78), and physically inactive adults were less likely to be scsome physical activity (50% vs. 59%; OR= 0.75; 95% CI, 0.63– 0.89). 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY:	 Authors, ref ID: Thorpe, L.E., et al.59 

Year of publication: 2005 Dates of data collection: 2003 Trial name: NA 

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•	 Adults who did not receive an influenza vaccination in the past 12 months were l

screened than those who did obtain the vaccination (46% vs. 66%, OR= 0.44; 95

•	 Simultaneous adjustment for multiple covariates tended to reduce the magnitude 

recent colorectal cancer screening by any modality across racial and ethnic groupersons. 

•	 Factors significantly associated with not having a colonoscopy within the past 10 

years (AOR= 0.68; 95%CI, 0.54–0.86), black or Asian ethnicity (black AOR = 0.7Asian AOR= 0.36, 95%CI, 0.22– 0.58), and female gender (AOR= 0.74, 95% CI, 

KQ3 - Which strategies are effective in Outcomes: 

increasing the appropriate use of
 colorectal cancer screening and NA
 followup?
 KQ4 - What are the current and Outcomes: projected capacities to deliver colorectal cancer screening and NA
 surveillance at the population level? KQ5 - What are the effective approaches Outcomes: for monitoring the use and quality of colorectal cancer screening? NA QUALITY RATING: Fair 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

Quality Assessment-Internal Validity for Observational Studies 

Yes No Other (CD, NR, 

C-217
 

Were the groups similar at baseline regarding the most important prognostic NA 

indicators? Were the drop-out or response rates acceptable (≤ 20%)? [If between 20% Cooperation rateand 60%, check other and explain.] rate=26% Were the differential drop-out or response rates acceptable (≤ 15%)? NA 

Were intervention/exposure measures valid, reliable, and equally applied? NA Were the outcome assessors blinded to the intervention or exposure status NA of subjects? Were outcome measures valid, reliable, and equally applied? X Does the analysis control for baseline differences? X Were important potential confounding and modifying variables taken into X account in the design and analysis (e.g., through matching, stratification, or statistical adjustment)? Were the statistical methods used to assess the abstracted outcomes X appropriate? Quality Rating (Good, Fair, or Poor): Fair Reviewer #1 initials: BLM Reviewer #2 initials: DJH Comments (explain poor quality ratings): 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

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STUDY:	 Authors, ref ID: Trivers, K.F., Shaw, K.M., Sabatino, S.A., Shapiro, J.A., Coates, R.J.60 

Year of publication: 2008 Dates of data collection: 2000 and 2005 Trial name: NA 

OBJECTIVE OR AIM: This study aimed to determine whether progress was made between 2000 and 2005 in reducin

disparities by race, ethnicity, income, and insurance status. 

DESIGN: Setting: Household survey 

Study design: Longitudinal, cross-secDuration (mean followup): 5-year folOverall study size (N enrolled/N ana

tional study 

low-up 

lyzed): n=6020 in 2000, n=6706 in 2005 

Sample size: 2000 2005 

Sample size = 6,020 Sample size = 6,706 

Describe intervention: Intervention: NHIS cancer control Intervention: NHIS cancer control 

supplement supplement 

RECRUITMENT: Population-based (population-based, clinic-based, volunteer, other) INCLUSION CRITERIA: Respondents to the 2000 and 2005 NHIS cancer control supplements, age 50-64, civilian, non

EXCLUSION CRITERIA: History of CRC POPULATION CHARACTERISTICS: 2000	 2005 

Age: 41.9% 50-54, 32% 55-59, 26.1% Age: 39.9% 50-54, 33.6% 55-59, 

Mean age & range (years): 60-64 26.5% 60-64 Sex (% female): Sex: 51.9% Sex: 51.8% female Race: Race: 84.8% White, 9.8% Black, 2.9% Race: 85% White, 10.7% Black, 

Asian, .7% AI/AN, 1.7% Other 3.2% Asian, .8% AI/AN, .2% Other 

Other: 

2000 2005 

Attrition/Drop-out (not available for 72.1% response rate for cancer control 69.0% response rate for cancer endpoint measurement): supplements control supplements Adherence: Contamination: Response Rates (e.g. for surveys): 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY:	 Authors, ref ID: Trivers, K.F., Shaw, K.M., Sabatino, S.A., Shapiro, J.A., Coates, R.J.60 

Year of publication: 2008 Dates of data collection: 2000 and 2005 Trial name: NA 

STATISTICAL ANALYSES: Describe: 

•	 For each group of interest, the percentages of respondents reporting screening w

frame and 95% CIs were calculated, stratified by gender, and age-adjusted withi

•	 Changes in disparities over time (from 2000 to 2005) were present if CIs for the d

percentages did not overlap or exhibited only minimal overlap. 

•	 Multivariate logistic regression analysis, stratified by gender, was used to estima

adjusted for age, race, ethnicity, poverty ratio, insurance status, education, regioresidence 

ASSESSMENT OF EXPOSURES AND POTENTIAL CONFOUNDERS: 

NR 

OUTCOME ASSESSMENT: Outcome Measures: 

Up-to-date with CRC screening 

RESULTS: 

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KQ2 - What factors influence the use of colorectal cancer screening? 

Outcomes: 

•	 Among men, the percentages screened in 2005 were higher than those in 2000 f

Hispanic men, those with middle or high incomes, and those with private insuransignificant increase in screening over time was among middle-income men (7.4 pCI=1.8, 12.9). The uninsured made the least progress over time and had the lowboth years (e.g., 19.1%, CI=14.6, 24.5 in 2005). 

•	 In 2005, Asian men continued to report the lowest screening of any racial group 

reporting screening, a 12.0 percentage-point difference compared to white men. men reported less screening than non-Hispanic men, as did men with lower comincomes. 

•	 The largest disparity was associated with being uninsured, and no reduction in th

over time. 

•	 Screening did not increase among Hispanic women or uninsured women (27.1%

19.3%, CI=15.7, 23.4 in 2005, respectively). Asian women had the largest gain in 38.5%, CI=27.6, 50.7); however, they had the lowest observed screening rate of examined among women. 

•	 In 2005, uninsured women were least likely to be screened. 

•	 Disparities associated with Hispanic ethnicity, low income, and being uninsured w

versus 2000. The difference between Hispanic and non-Hispanic women in 2000 points (CI=3.0, 14.6). This gap rose to 19.3 percentage points (CI=13.6, 25.0) in 

KQ3 - Which strategies are effective Outcomes: 

in increasing the appropriate use of NA colorectal cancer screening and
 followup?
 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY: Authors, ref ID: Trivers, K.F., Shaw, K.M., Sabatino, S.A., Shapiro, J.A., Coates, R.J.60 

Year of publication: 2008 Dates of data collection: 2000 and 2005 Trial name: NA 

KQ4 - What are the current and Outcomes: projected capacities to deliver colorectal cancer screening and surveillance at the population level? 

NA 

KQ5 - What are the effective Outcomes: approaches for monitoring the use and quality of colorectal cancer screening? 

NA 

QUALITY RATING: Fair 

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Quality Assessment-Internal Validity for Observational Studies 

Yes No Other (CD, NR, NA) 

Were the groups similar at baseline regarding the most important prognostic X 

indicators? Were the drop-out or response rates acceptable (≤ 20%)? [If between 20% 72.1% response rate fand 60%, check other and explain.] supplements in 2000, Were the differential drop-out or response rates acceptable (≤ 15%)? X 

Were intervention/exposure measures valid, reliable, and equally applied? NA 

Were the outcome assessors blinded to the intervention or exposure status NA 

of subjects? Were outcome measures valid, reliable, and equally applied? X Does the analysis control for baseline differences? X Were important potential confounding and modifying variables taken into X account in the design and analysis (e.g., through matching, stratification, or statistical adjustment)? Were the statistical methods used to assess the abstracted outcomes X appropriate? Quality Rating (Good, Fair, or Poor): Fair Reviewer #1 initials: BLM Reviewer #2 initials: DJH Comments (explain poor quality ratings): 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY:	 Authors, ref ID: Walsh JME et al.61 

Year of publication: 2004 Dates of data collection: November 2001 to June 2002 Trial name: NA 

OBJECTIVE OR AIM: To identify current colorectal cancer screening practices and barriers and facilitators to colore

in Latino, Vietnamese, and non-Latino white populations in San Jose, California 

DESIGN: Setting: Telephone survey amongst Latino, Vietnamese, and non-Latino whites aged 50 to 7

Jose (Santa Clara County), California Study design: Cross-sectional Duration (mean followup): NA Overall study size (N enrolled/N analyzed): 1,559 contacted, 775 enrolled (50%) 

White Latino Vie

Sample size: N=310 N=226 

Describe intervention: NA NA 

RECRUITMENT: Community-based (population-based, clinic-based, 

C-221 volunteer, other) 
 

INCLUSION CRITERIA:	 • 50 to 79 years old 

• Self identified as white, Latino, or Vietnamese. • Able to communicate in either English, Spanish, or Vietnamese 

EXCLUSION CRITERIA:	 • Those not within the target age group and population 

POPULATION CHARACTERISTICS: Mean age & range (years): Sex (% female): Race: Other: 

• Education • Insurance (%) • Income (median) 

• Acculturation (%) • Marital status • Having a regular 

Total: Educational level, insurance status, median income, employment status, marital status

physician, and having been to the doctor in past 12 months were significantly different (P < 0

groups 

• 61 (±8) • 50.5%F • 40% white • 29.2% Latino • 30.8% Vietnamese • 42.4% ≤ High School education 

• 6.7% Uninsured • $50,000 • 48% low • 69.9% married 

• 87.1% 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY:	 Authors, ref ID: Walsh JME et al.61 

Year of publication: 2004 Dates of data collection: November 2001 to June 2002 Trial name: NA 

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physician 

Overall 

Attrition/Drop-out (not available for 50% of those contacted and eligible refused to participate endpoint measurement): Adherence: Contamination: Response Rates (e.g. for surveys): • 40% white 

• 29.2% Latino 

• 30.8% Vietnamese 

STATISTICAL ANALYSES: • Descriptive statistics for demographic and dependent variables 

•	 Univariate analysis (Student’s t test and logistic regression) to determine assoc

variables (age, gender, ethnicity, acculturation, education, income and insurancvariables (bring up-to-date for screening and intention to be screened) 

•	 Multivariate analysis: Multivariate regression analysis to determine which predic

significant when correcting for other variables 

ASSESSMENT OF EXPOSURES AND Multivariate regression analysis to account for age, gender, ethnicity, acculturation, education

POTENTIAL CONFOUNDERS: income OUTCOME ASSESSMENT: Outcome Measures: 

•	 Unadjusted Screening rates for FOBT in the past year or sigmoidoscopy in the 

colonoscopy in the past 10 years or receipt of any of the tests in the recommend

•	 Predictors of being up-to-date with colon screening: FOBT in the past year or si

past 5 years or colonoscopy in the past 10 years or receipt of any of the tests in interval 

•	 Predictors of intention to be screened: Plan to have FOBT in next year or s

next 5 years or colonoscopy in the next 10 years or planning to have any of the recommended time interval 

RESULTS: KQ2 - What factors influence the use The biggest predictor of having had a sigmoidoscopy or colonoscopy was physician recomme

of colorectal cancer screening? CI, 2.34-18.08). Because this was such a strong factor, excluding it from the analysis allowed 

variables to be explored. Outcomes: FOBT in past yr SIG in past 5 yrs COL in past 10 

Unadjusted screening rates: 

• White 19% 35.5% 30.6% 

• Latino 18.1% 29.2% 27% 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY: Authors, ref ID: Walsh JME et al.61 

Year of publication: 2004 Dates of data collection: November 2001 to June 2002 Trial name: NA 

• Vietnamese 31.4% 18.4% 21.8% 

Adjusted predictors of being up-to-date (OR, 95% CI) 

• Age (per 5 

yrs) 

• Gender (male) 

(OR, 95% CI) 

1.22 (1.04-1.44) 0.89 (0.60-1.31) 

(OR, 95% CI) 

1.22 (1.05-1.43) 1.44 (0.96-2.16) 

(OR, 95% CI

1.19 (1.02-1.31.36 (0.91-2.0

Ethnicity (compared with white) 

• Latino 

1.01 (0.52-1.94) 1.37 (0.49-3.86) 

0.90 (0.52-1.56) 

0.26 (0.09 -0.72) 

1.27 (0.73-2.20.65 (0.30-1.4

• Vietnamese 

• Acculturation 

(low) 

• Education 

0.87 (0.38-1.99) 0.89 (0.73-1.09) 1.05 (0.90 -1.23) 0.97 (0.38- 2.50) 

1.71 (0.84-3.48) 1.51 (0.86-1.27) 0.99 (0.87-1.14) 0.44 (0.15-1.34) 

0.96 (0.49-1.8

1.01 (0.83-.23

1.02 (0.90-1.10.31 (0.10-0.9

• Income • No Insurance 

(compared 

 with medicare) 

Adjusted Predictors of intention to be screened 

• Age (per 5 

yrs) 

• Gender 

1.12 (0.95-1.32) 1.09 (0.76-1.56) 1.18 (0.66-2.12) 1.70 (0.71-4.05) 

0.97 (0.84-1.14) 1.29 (0.91-1.83) 

1.41 (0.79-2.52) 

1.52 (0.70-3.29) 

0.92 (0.78-1.01.05 (0.71-1.5

2.04 (1.07-3.88) 

1.19 (0.50-2.8

Ethnicity (compared with white) 

• Latino 

• Vietnamese 

• Acculturation (low) • Education 

1.81 (0.91-3.58) 0.96 (0.79-1.16) 0.96 (0.84-1.08) 0.56 (0.23-1.34) 

2.19 (1.12-4.28 

1.07 (0.89-1.29) 1.03 (0.87-1.23) 0.43 (0.18-1.01) 

1.86 (0.90-3.81.06 (0.87-1.21.01 (0.88-1.10.95 (0.38-2.3

• Income • No Insurance 

(compared with Medicare) 

KQ3 - Which strategies are effective in increasing the appropriate use of colorectal cancer screening and 

NA 

C-223
 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY: Authors, ref ID: Walsh JME et al.61 

Year of publication: 2004 Dates of data collection: November 2001 to June 2002 Trial name: NA 

followup? KQ4 - What are the current and NA projected capacities to deliver colorectal cancer screening and surveillance at the population level? KQ5 - What are the effective NA approaches for monitoring the use and quality of colorectal cancer screening? QUALITY RATING: Fair 

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Quality Assessment-Internal Validity for Observational Studies 

Yes No Other (CD, NR, N

Were the groups similar at baseline regarding the most important prognostic indicators? X Were the drop-out or response rates acceptable (≤ 20%)? [If between 20% and 60%, check other 

X 

and explain.] Were the differential drop-out or response rates acceptable (≤ 15%)? NR Were intervention/exposure measures valid, reliable, and equally applied? X Were the outcome assessors blinded to the intervention or exposure status of subjects? NR Were outcome measures valid, reliable, and equally applied? X Does the analysis control for baseline differences? X Were important potential confounding and modifying variables taken into account in the design and X 

analysis (e.g., through matching, stratification, or statistical adjustment)? Were the statistical methods used to assess the abstracted outcomes appropriate? X 

Quality Rating (Good, Fair, or Poor): Fair 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

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STUDY:	 Authors, ref ID: Wee, C.C., McCarthy, E.P., Philips, R.S.62 

Year of publication: 2004 Dates of data collection: 2000 Trial name: NA 

OBJECTIVE OR AIM: Understand the relative contribution of patient factors and physician counseling patterns to 

screening. 

DESIGN: Setting: Home; telephone survey: 2000 National Health Interview Survey with the Cancer 

Study design: Secondary data analysis Duration (mean followup): One-time survey collection during 2000 Overall study size (N enrolled/N analyzed): 11,427 

Sample size: All 

Sample Size: 11,427 

Describe intervention: No intervention, telephone survey RECRUITMENT: Population-based 

(population-based, clinic-based, volunteer, other) INCLUSION CRITERIA: Age 50-75, completed the national Health Interview Survey EXCLUSION CRITERIA: NR POPULATION CHARACTERISTICS: All 

Age range: 50-75 

Mean age & range (years): Sex (% female): Race: 

Mean age: 64 

Other: Attrition/Drop-out (not available for endpoint measurement): Adherence: Contamination: 

All Combined response of 72% to the supplement and core surveys 

Response Rates (e.g. for surveys): STATISTICAL ANALYSES: Describe: 

•	 Used descriptive statistics and bivariate analyses to characterize the sample

•	 Used multivariable logistic regression to examine the correlates of the colon 

outcomes 

ASSESSMENT OF EXPOSURES AND • Exposures, i.e. factors of interest were cited reasons for not having screenin

POTENTIAL CONFOUNDERS: about physician counseling. Participants asked what was the most importan
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY:	 Authors, ref ID: Wee, C.C., McCarthy, E.P., Philips, R.S.62 

Year of publication: 2004 Dates of data collection: 2000 Trial name: NA 

FOBT. 

•	 Other demographic factors were age, race/ethnicity, education, region of US

•	 Potential confounders included family history of CRC, healthcare access, sm

burden. 

OUTCOME ASSESSMENT: Outcome Measures: 

Respondents were asked if and when they ever have had FOBT, sigmoidoscopy, or colonSecondary Outcome: Reasons respondents did not have FOBT or sigmoidoscopy or colonoscopy 

RESULTS: KQ2 - What factors influence the use of Outcomes: colorectal cancer screening? • Sex, race/ethnicity, region, and health status were significant at the level of 

screening. 

• BMI was significant at the level of P<.001 for simoidoscopy/colonoscopy. 

• Education, insurance coverage, and usual source of care were significant at 

FOBT and sigmoidoscopy/colonoscopy. 

• Nonwhites less likely to have FOBT in unadjusted analysis. After adjustmen

and education were associated with screening. Hispanics and low SES were than their counterparts. 

• Hispanics and “other” (non-black, non white) less likely to report physician c

even when adjusted for other factors in the table (e.g. USOC). 

• Reasons that respondents did not have an FOBT (of 9017): 22% reported th

recommending it. Among respondents who gave a reason other than lack of recommendation for not completing FOBT, 5793 respondents had a provideof these, 94% reported that their doctor had not discussed FOBT with them. 

• Reasons that respondents did not have a sigmoidoscopy or colonoscopy (of 

physician not recommending it. Among the subset of respondents who gave physician advice, 5096 had a provider visit in the previous year; of these, 92did not recommend sigmoidoscopy or colonoscopy. 

KQ3 - Which strategies are effective in increasing the appropriate use of colorectal cancer screening and followup? 

Outcomes: NA 

KQ4 - What are the current and Outcomes: projected capacities to deliver colorectal cancer screening and surveillance at the population level? 

NA 

C-226
 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY:	 Authors, ref ID: Wee, C.C., McCarthy, E.P., Philips, R.S.62 

Year of publication: 2004 Dates of data collection: 2000 Trial name: NA 

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KQ5 - What are the effective approaches Outcomes: for monitoring the use and quality of NA colorectal cancer screening? QUALITY RATING: Fair Quality Assessment-Internal Validity for Observational Studies 

Yes No Other (CD, NR, 

Were the groups similar at baseline regarding the most important prognostic NA 

indicators? Were the drop-out or response rates acceptable (≤ 20%)? [If between 20% X combined respo

and 60%, check other and explain.] supplement and 

surveys 

Were the differential drop-out or response rates acceptable (≤ 15%)? NA 

Were intervention/exposure measures valid, reliable, and equally applied?	 NA 

Were the outcome assessors blinded to the intervention or exposure status NA of subjects? Were outcome measures valid, reliable, and equally applied?	 X 

Does the analysis control for baseline differences? X 

Were important potential confounding and modifying variables taken into X 

account in the design and analysis (e.g., through matching, stratification, or statistical adjustment)? Were the statistical methods used to assess the abstracted outcomes X appropriate? Quality Rating (Good, Fair, or Poor): Fair Reviewer #1 initials: BLM Reviewer #2 initials: DR Comments (explain poor quality ratings):. 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY:	 Authors, ref ID: Wong et al.63 

Year of publication: 2005 Dates of data collection: 2001 Trial name: NA 

OBJECTIVE OR AIM: To examine CRC screening rates among different Asian-American groups compared with 

factors related to CRC screening 

DESIGN: Setting: California 

Study design: population-based telephone survey Duration (mean follow-up): NA Overall study size (N enrolled/N analyzed): 19,489 

Asian Americans Non-Latino whites 

Sample size: 1, 771 17,718 Describe intervention: NA NA 

RECRUITMENT: random digit dialing, list samples 

(population-based, clinic-based, volunteer, other) 

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 INCLUSION CRITERIA:	 Asian-Americans, non-Latino whites, 50 years and older EXCLUSION CRITERIA: Individuals who had CRC (n = 162); Cambodians were excluded from analysis because o

age criteria 

POPULATION CHARACTERISTICS: Mean age & range (years): Sex (% female): Education (%) Grade lt 12 HS grad, some college  College graduate or more Married Born in US (%) Uninsured (%) 0-99% FPL 100-199% FPL ≥ 300% FPL 

Chinese 

62.56 

54 22 39 39 78 14 

9 

24 20 44 

Fillipino 

61.58 

56 

9 

43 48 71 

6 

10 80 26 48 

South Asian 

56.77 

42 

2 

22 76 83 

2 

10 

7 4 

77 

Japanese 

65.97 

58 

2 

59 39 70 82 

1 4 

18 63 

Korean 

62.21 

56 21 35 44 79 

2 

32 19 30 36 

Vie
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY:	 Authors, ref ID: Wong et al.63 

Year of publication: 2005 Dates of data collection: 2001 Trial name: NA 

Attrition/Drop-out (not available for 

endpoint measurement): NA Adherence:
 Contamination: Response Rates (e.g. for surveys): STATISTICAL ANALYSES: Describe: Descriptive statistics were computed for all sociodemographic and dependent v

and standard errors for continuous data and frequency distributions for each categorical vanalyses, chi-square tests and t tests were used to determine any significant ethnic differesociodemographics and CRC screening outcomes. Six multivariate logistic regression models were used to assess the extent to which ethnic screening were explained by predisposing, enabling, and need factors. All reported ORs wsignificant at the P < 0.05 level. 

C-229
 

ASSESSMENT OF EXPOSURES AND POTENTIAL CONFOUNDERS: 

Predisposing variables that were controlled for included ethnic group (Chinese, Filipino, SKorean, Vietnamese, and non-Latino white), age, gender, educational attainment (≤ Grad

undergraduate degree or greater), marital status, household size (1, 2, or ≥ 3 individuals), 

(< 15 yrs, ≥ 15 yrs), English-language proficiency, income (0%-99% of the FPL, 100%-199of the FPL, and ≥ 300% of the FPL), comorbid conditions (diabetes or cardiovascular dise

of CRC. Enabling variables that were controlled for included insurance status (public, private, or uncare (yes or no), and the number of physician visits in the last year. 

Need variables that were controlled for included both physical and mental health, which w

(higher score = better health), general health status, and limitation of activities. 

They also included a variable that accounted for the data collection method (RDD sample 

OUTCOME ASSESSMENT: Outcome Measures: 

Whether individuals ever had CRC screening; whether individuals were up to date for CRC was considered up to date if she/he had undergone either FOBT in past yr or endoscopy 

RESULTS: KQ2 - What factors influence the use of Outcomes: colorectal cancer screening? Bivariate 

• Receipt of CRC screening low for all groups 

• Asian Americans had lower rates compared with non-Latino whites (P < 0.00

• Non-Latino whites had highest rate of undergoing FOBT (58%), endoscopy 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY:	 Authors, ref ID: Wong et al.63 

Year of publication: 2005 Dates of data collection: 2001 Trial name: NA 

C-230
 

screening (75%) 

•	 Asian American rates were 38% for FOBT, 42% for endoscopy and 58% for 

•	 Koreans had lowest rate of undergoing FOBT (23%) and any screening (49%•	 Vietnamese had lowest rate of undergoing endoscopy (36%) •	 Japanese rates for all three CRC screening outcomes similar to non-Latino w

Multivariate 

•	 After controlling for predisposing, enabling and need variables, the only ethn

non-Latino whites to have undergone FOBT was Koreans (OR 0.40; 95% C

•	 Other predisposing factors associated with significantly lower receipt of FOB

(OR 0.90; 95% CI: 0.83, 0.97), those who lived in households with ≥ 3 indivi

0.74, 0.87), those who lived in US for < 15 yrs (OR 0.56; 95% CI: 0.38, 0.83income < 300% of FPL 

•	 Individuals more likely to have undergone FOBT included those who were o

1.01, 1.03), college graduates (OR 1.70; 95% CI: 1.42, 2.03), and those with 

cancer (OR 1.77; 95% CI: 1.43, 2.19) 

•	 Significant enabling factors for FOBT receipt were having either public insur

1.53, 2.61), or private insurance (OR 1.59; 95% CI: 1.30, 1.95), having a usu2.49; 95% CI: 1.97, 3.14) 

•	 Need factors associated with undergoing FOBT included more physician vis

1.05) 

•	 All Asian-American ethnic groups had similar rates of being up to date with F

Latino whites 

•	 One predisposing factor was associated with individuals who were significan

date with FOBT: living in households with ≥ 3 individuals (OR 0.68; 95% CI: 

•	 Individuals more likely to be up to date with FOBT screening if they were ma

1.24, 1.62), if they had a family history of colon cancer (OR 1.77; 95% CI: 1.public health insurance (OR 2.00; 95% CI: 1.53, 2.61), or private health insu1.30 , 1.95), if they had more physician visits (OR 1.04; 95% CI: 1.02, 1.05), of care (OR 2.49; 95% CI: 1.97, 3.14), and if they had better physical health 

1.01) or better mental health (OR 1.00; 95% CI: 1.00, 1.01) 

•	 Filipinos were less likely to be up to date with endoscopy (OR 0.68; 95% CI: 

•	 Individuals significantly less likely to be up to date with endoscopy if they live

individuals (OR 0.79; 95% CI: 0.69, 0.90), if they had lived in US for < 15 yrs 0.69), or if they had a family income < 200% of FPL 

•	 Additional predisposing factors associated significantly with being up to date 

male gender (OR 1.54; 95% CI: 1.44, 1.65), and having a greater educationgraduate: OR 1.34; 95% CI: 1.13, 1.57; college graduate: OR 1.85; 95% CI: 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY:	 Authors, ref ID: Wong et al.63 

Year of publication: 2005 Dates of data collection: 2001 Trial name: NA 

KQ3 - Which strategies are effective in Outcomes: 

increasing the appropriate use of NA colorectal cancer screening and
 followup?
 KQ4 - What are the current and Outcomes: projected capacities to deliver NA colorectal cancer screening and
 surveillance at the population level? KQ5 - What are the effective approaches Outcomes: for monitoring the use and quality of NA colorectal cancer screening? QUALITY RATING: Fair 

C-231
 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

Quality Assessment-Internal Validity for Observational Studies 

Yes No Other (CD, NR, 

C-232
 

Were the groups similar at baseline regarding the most important prognostic X Significant differ

indicators? sociodemographWere the drop-out or response rates acceptable (≤ 20%)? [If between 20% N/A and 60%, check other and explain.] Were the differential drop-out or response rates acceptable (≤ 15%)? N/A Were intervention/exposure measures valid, reliable, and equally applied? X Were the outcome assessors blinded to the intervention or exposure status 

X 

of subjects? Were outcome measures valid, reliable, and equally applied? X Does the analysis control for baseline differences? X Were important potential confounding and modifying variables taken into X account in the design and analysis (e.g., through matching, stratification, or statistical adjustment)? Were the statistical methods used to assess the abstracted outcomes X appropriate? Quality Rating (Good, Fair, or Poor): Fair Reviewer #1 initials: LCM Reviewer #2 initials: DJH Comments (explain poor quality ratings): 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

C-233
 

STUDY:	 Authors, ref ID: Yano, E., Soban, L., Parkerton, P., Etzioni, D.64 

Year of publication: 2006 Dates of data collection: 1999-2001 Trial name: NA 

OBJECTIVE OR AIM: To identify primary care practice characteristics associated with colorectal cancer (CRC) s

controlling for patient-level factors. 

DESIGN: Setting: VA Primary care clinics 

Study design: Cross-sectional Duration (mean followup): No follow-up, data duration of 2 years Overall study size (N enrolled/N analyzed): 155 facilities; 38.818 patients 

Patients Group 2 

Sample size: Sample Size: 38,818 

Intervention: none, data collected 

Describe intervention: on CRC screening RECRUITMENT: Clinic-based; VA Survey of Primary Care Practices 

(population-based, clinic-based, volunteer, other) INCLUSION CRITERIA: Physician chiefs at all VA facilities serving 4,000 or more outpatients and providing 20,000 

in FY98 

EXCLUSION CRITERIA:	 Patients over age 86; patients with a prior history of CRC, inflammatory bowel disease, or 

POPULATION CHARACTERISTICS:	 Patients 

Age: 31.3% 52-64, 36.3% 65-74, 

Mean age & range (years): 32.4% 75-85 Sex (% female): Sex: 10.8% female Race: Race: 86.2% White, 11.1% Black, 

2.8% Other 

Other: 

All 

Attrition/Drop-out (not available for VA Survey of Primary Care endpoint measurement): Practices 93% response rate Adherence: Contamination: Response Rates (e.g. for surveys): STATISTICAL ANALYSES: Describe: 

•	 Linked organizational data (n=155 primary care clinics) with the patient-leve

station identifiers from which each patient was sampled, confirmed through evisit patterns. 

•	 Evaluated relationships between hypothesized organizational predictors and 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY:	 Authors, ref ID: Yano, E., Soban, L., Parkerton, P., Etzioni, D.64 

Year of publication: 2006 Dates of data collection: 1999-2001 Trial name: NA 

C-234
 

screening rates using correlation coefficients for continuous variables and Avariables, applying a cutpoint of P <= .10 as inclusion criterion. 

•	 Included these organizational measures in logistic regression to estimate the 

organizational characteristics on a patient’s probability of receipt of CRC scrcluster effects and patient-level covariates associated with screening. 

ASSESSMENT OF EXPOSURES AND NR POTENTIAL CONFOUNDERS: OUTCOME ASSESSMENT: Outcome Measures:
 

CRC screening is documented as evidence of (1) three returned FOBT cards in the prior 1of a flexible sigmoidoscopy in the last 5 years, or (3) performance of a colonoscopy in the patients 52 years and older. 

RESULTS: KQ2 - What factors influence the use of	 Outcomes: 

colorectal cancer screening? •	 Authority over the internal structure and operations of the practice was signi

CRC screening (r=0.18; P<.01) (centralization), as was the sufficiency of clin

(r=0.22; P<.001) (resources). 

•	 Facility size was significantly, negatively correlated with CRC screening (r= 

•	 After adjusting for region and individual patient characteristics, patients who 

primary care practice characterized by higher centralization (as measured bautonomy) (P<.04) and resources (as measured by sufficiency of clinical sup(P<.03) were significantly more likely to receive CRC screening. 

•	 Overall screening rate 62.2%. No other absolute screening rates reported 

KQ3 - Which strategies are effective in Outcomes: 

increasing the appropriate use of NA colorectal cancer screening and
 followup?
 KQ4 - What are the current and Outcomes: projected capacities to deliver NA colorectal cancer screening and
 surveillance at the population level?
 KQ5 - What are the effective approaches Outcomes: for monitoring the use and quality of NA colorectal cancer screening? QUALITY RATING: Fair 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

Quality Assessment-Internal Validity for Observational Studies 

Yes No Other (CD, NR, 

C-235
 

Were the groups similar at baseline regarding the most important prognostic 

X 

indicators? Were the drop-out or response rates acceptable (≤ 20%)? [If between 20% X VA Survey of 

and 60%, check other and explain.] Primary Care Pr

response rate 

Were the differential drop-out or response rates acceptable (≤ 15%)? X 

Were exposure measures valid, reliable, and equally applied? X Were the outcome assessors blinded to the intervention or exposure status X 

of subjects? Were outcome measures valid, reliable, and equally applied? X Does the analysis control for baseline differences? X Probably others 

Were important potential confounding and modifying variables taken into uncertain account in the design and analysis (e.g., through matching, stratification, or statistical adjustment)? Were the statistical methods used to assess the abstracted outcomes X appropriate? Quality Rating (Good, Fair, or Poor): Fair Reviewer #1 initials: BLM Reviewer #2 initials: RPH Comments (explain poor quality ratings): 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

C-236
 

STUDY:	 Authors, ref ID: Yip et al.65 

Year of publication: 2006 Dates of data collection: July 2003- Sept 2004 Trial name: Part of a Randomized trial (Tu et al., 2006- included under KQ3) 

OBJECTIVE OR AIM: To describe CRC screening among less acculturated Chinese Americans and to identify f

screening 

DESIGN: Setting: Primary care clinic 

Study design: retrospective chart review Duration (mean follow-up): NA Overall study size (N enrolled/N analyzed): 383 

Sample size: Group 1 Group 2 

383 

Describe intervention: 

NA 

RECRUITMENT: Chinese patients seen at a community clinic providing primary medical services to Asian a(population-based, clinic-based, Seattle volunteer, other) INCLUSION CRITERIA:	 none were given other than they had to be of Chinese decent and patients of the clinic 

EXCLUSION CRITERIA:	 greater acculturation (fluent in English, n = 3) 

POPULATION CHARACTERISTICS: Group 1	 Group 2 

Mean age & range (years): 50-64, n=193 (50%) 

65+, n=191 (50%) 

Sex (% female): 63.2% female Race: 100% Asian/Chinese 

5.2% uninsured 

Other: 100% used an Asian language as 

their primary language 

Group 1 Group 2 

Attrition/Drop-out (not available for NA endpoint measurement): Adherence: Contamination: Response Rates (e.g. for surveys): STATISTICAL ANALYSES: Describe: 

descriptive statistics and then Chi-square 

ASSESSMENT OF EXPOSURES AND Age, gender, insurance status, language POTENTIAL CONFOUNDERS: 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY: Authors, ref ID: Yip et al.65 

Year of publication: 2006 Dates of data collection: July 2003- Sept 2004 Trial name: Part of a Randomized trial (Tu et al., 2006- included under KQ3) 

OUTCOME ASSESSMENT: Outcome Measures: 

Whether patients had received screening per USPSTF guidelines 

RESULTS: 

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KQ2 - What factors influence the use of	 Outcomes: 

colorectal cancer screening?	 Overall, 39.7% were assessed as being screened for CRC according to guidelines. Of the

FOBT in past year, 2.9% completed FS in past 5 years, and 21.3% completed colonoscopwas no significant differences for users and non-users of any of the CRC tests (FOBT, sigage, gender, insurance status, or language were found. 

KQ3 - Which strategies are effective in Outcomes: NA increasing the appropriate use of colorectal cancer screening and followup? KQ4 - What are the current and Outcomes: NA projected capacities to deliver colorectal cancer screening and surveillance at the population level? KQ5 - What are the effective approaches Outcomes: NA for monitoring the use and quality of colorectal cancer screening? QUALITY RATING: Fair 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

Quality Assessment-Internal Validity for Observational Studies 

Yes No Other (CD, NR, 

C-238
 

Were the groups similar at baseline regarding the most important prognostic NR 

indicators? Were the drop-out or response rates acceptable (≤ 20%)? [If between 20% N/A and 60%, check other and explain.] Were the differential drop-out or response rates acceptable (≤ 15%)? N/A Were intervention/exposure measures valid, reliable, and equally applied? NR 

Were the outcome assessors blinded to the intervention or exposure status X health educator, 

of subjects? person providing 

the Tu paper is treviewed the ch

Were outcome measures valid, reliable, and equally applied? X Does the analysis control for baseline differences? N/A Were important potential confounding and modifying variables taken into X as an example, 

account in the design and analysis (e.g., through matching, stratification, or about language statistical adjustment)? only included pa

Asian language language (i.e., n

Were the statistical methods used to assess the abstracted outcomes X appropriate? Quality Rating (Good, Fair, or Poor): Fair Reviewer #1 initials: DJH Reviewer #2 initials: LCM Comments (explain poor quality ratings): 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

C-239
 

STUDY:	 Authors, ref ID: Young, W.F., McGloin, J., Zittleman, L., West, D.R., Westfall, J.M.66 

Year of publication: 2007 Dates of data collection: Spring 2005, for 2 weeks Trial name: Testing to Prevent Colon Cancer in Rural Colorado 

OBJECTIVE OR AIM: To establish baseline attitudinal, knowledge, belief, and behavior measures on colorectal ca

identify barriers to or predictors of colorectal cancer screening. 

DESIGN: Setting: High Plains Research Network (HPRN), a practice-based research network in 9 ru

and frontier counties in northeast Colorado Study design: Baseline telephone survey Duration (mean followup): NA, no follow-up Overall study size (N enrolled/N analyzed): 1,050 respondents Sample 

Sample size: Sample size: 1,050 respondents 

The authors conducted a baseline random-digit dialing telephone survey to assess colon ca

Describe intervention: screening behaviors among people 50 years old and older. RECRUITMENT: Random-digit dialing telephone survey
 

(population-based, clinic-based, volunteer, other) INCLUSION CRITERIA:	 Age 50+ 

EXCLUSION CRITERIA:	 NR POPULATION CHARACTERISTICS:	 Sample 

Mean age: 65.3 

Mean age & range (years): 67.1% female Sex (% female): 88.4% Caucasia, .2% African American, .4% Asian, .5% Native Hawaiian/Pacific Islander, 1

Race: Indian/Alaskan Native, 7.6% Other 

9.6% Hispanic 

Attrition/Drop-out (not available for 51.6% response rate 

endpoint measurement): Adherence:
 Contamination: Response Rates (e.g. for surveys): STATISTICAL ANALYSES: Describe: 

• Used t tests for continuous variables and chi-square tests for categorical varia

•	 Performed logistic regression modeling 

•	 To test the hypothesis that the geographic distance to colorectal cancer scree

related to screening rates, the authors conducted 2 geographical information 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY:	 Authors, ref ID: Young, W.F., McGloin, J., Zittleman, L., West, D.R., Westfall, J.M.66 

Year of publication: 2007 Dates of data collection: Spring 2005, for 2 weeks Trial name: Testing to Prevent Colon Cancer in Rural Colorado 

ASSESSMENT OF EXPOSURES AND POTENTIAL CONFOUNDERS: 

Logistic regression modeling. Covariates included: age, gender, race/ethnicity, marital statueducational level, employment status, and household income, when the respondent had las

health care practitioner for a checkup, requesting a colorectal cancer test at last visit, wheth

cancer ranked as a cause of death, level of agreement with the statement “Testing can idenbefore colorectal cancer can start,” family and personal history of colorectal cancer, personperceived chances of getting colorectal cancer, the likelihood of preventing and curing coloin a ZIP code with a hospital. 

OUTCOME ASSESSMENT: Outcome Measures: 

•	 Compared colorectal cancer knowledge and screening behavior between maj

•	 Used the standard American Cancer Society guidelines to define up-to-date o

screening (yearly FOBT, flexible sigmoidoscopy every 5 years, barium enema colonoscopy every 10 years). 

RESULTS: 

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KQ2 - What factors influence the use of colorectal cancer screening? 

Outcomes: 

•	 Sixty-three percent reported they ever had an FOBT, but only 50% of those (3

•	 Participants who were of 65 years or older, married, Hispanic, or had an incom

more likely to be up-to-date. 

•	 Being up-to-date on this test was also associated with seeing a doctor or othe

the past year (O.R. = 1.2, 95% C.I.1.16-1.27) or having asked for a screening 2.08-2.86). 

•	 Thirty-four percent had ever had sigmoidoscopy, with 28% up-to-date. •	 Persons 50-64 years old were more than twice as likely as those 65 years old 

reasons” (23.0% vs 10.3%, P < .001) as a reason for not having this test. 

•	 Nearly half (48.3%) of the Hispanic study participants reported that they “neve

compared to 35.7% of non-Hispanics (P < .05). 

•	 Hispanics were also more likely to report “financial reasons” for not having ha

(24.1% vs 17.2%, P < .05). 

•	 Forty-three percent reported they ever had a colonoscopy and 38% were up-t

•	 Being up-to-date on colonoscopy was associated with having seen a doctor o

the past year, asking for a colon cancer test from their doctor, believing that thcolorectal cancer were greater than average and having a family history of co

•	 Participants who were Hispanic, unemployed, low income or were 50-64 year

financial reasons for not having this test (P < .001 for all). Hispanics were also 

they never heard of this test (28.0% vs 14.8% all others, P = .02). 

• Only 29% had ever had a barium enema and only 13% were up-to-date. 

•	 Thirteen percent reported they ever had a virtual colonoscopy and only 2% of 

this test planned to have it in the next year. 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY:	 Authors, ref ID: Young, W.F., McGloin, J., Zittleman, L., West, D.R., Westfall, J.M.66 

Year of publication: 2007 Dates of data collection: Spring 2005, for 2 weeks Trial name: Testing to Prevent Colon Cancer in Rural Colorado 

C-241
 

•	 Up-to-date screening rates for participants residing in ZIP codes with a health 

than those without a health facility: clinic (59.6% with clinic vs 58.2% without c

(59.4% with hospital vs 57.3% without hospital, P = .49), hospital or clinic (59

without a facility, P = 0.38). 

•	 Demographic predictors of being up-to-date on at least 1 colorectal cancer tes

older (OR = 1.40; 95% CI = 1.22-1.61) or married (OR = 1.14; 95% CI = 1.02-

KQ3 - Which strategies are effective in Outcomes: 

increasing the appropriate use of NA colorectal cancer screening and
 followup?
 KQ4 - What are the current and Outcomes: projected capacities to deliver NA colorectal cancer screening and
 surveillance at the population level?
 KQ5 - What are the effective Outcomes: approaches for monitoring the use and NA quality of colorectal cancer screening? QUALITY RATING: Fair 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

Quality Assessment-Internal Validity for Observational Studies 

Yes No Other (CD, NR, 

C-242
 

Were the groups similar at baseline regarding the most important prognostic NA 

indicators? Were the drop-out or response rates acceptable (≤ 20%)? [If between 20% 

X 

and 60%, check other and explain.] Were the differential drop-out or response rates acceptable (≤ 15%)? NA 

Were intervention/exposure measures valid, reliable, and equally applied? NA Were the outcome assessors blinded to the intervention or exposure status NA 

of subjects? Were outcome measures valid, reliable, and equally applied? X Does the analysis control for baseline differences? X Were important potential confounding and modifying variables taken into X account in the design and analysis (e.g., through matching, stratification, or statistical adjustment)? Were the statistical methods used to assess the abstracted outcomes X appropriate? Quality Rating (Good, Fair, or Poor): Fair Reviewer #1 initials: BLM Reviewer #2 initials: DR; LCM Comments (explain poor quality ratings): 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY:	 Authors, ref ID: Zapka et al.67 

Year of publication: Dates of data collection: 2002 Trial name: NA 

C-243
 

OBJECTIVE OR AIM: Assess the role of insurance status, type of plan, frequency of preventive health visits, and 

on utilization of CRC screening tests. 

DESIGN: Setting: Telephone survey 

Study design: Cross-sectional, random-digit-dial survey Duration (mean followup): June to August 1998 Overall study size (N enrolled/N analyzed): 1,002 

Sample size: Population Describe intervention: Sample Size = 1,002 RECRUITMENT: Population-based; A random-digit-dial telephone survey; Three samples—a basic random (population-based, clinic-based, oversample, and a racial/ethnic minority oversample targeting African Americans and Hispvolunteer, other) the Kish sampling method INCLUSION CRITERIA: Participants were Massachusetts residents, aged ≥ 50, who had a working residential tele

never been diagnosed with CRC. 

EXCLUSION CRITERIA: POPULATION CHARACTERISTICS:	 Population 

Age 50+ 

Mean age & range (years): Sex: 57% Sex (% female): Race: 90.1% White, 4% African Race: American/other; 4.9% Hispanic Other: 

Population 

Attrition/Drop-out (not available for endpoint measurement): Response rate = 64% Adherence: Contamination: Response Rates (e.g. for surveys): 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY:	 Authors, ref ID: Zapka et al.67 

Year of publication: Dates of data collection: 2002 Trial name: NA 

STATISTICAL ANALYSES: Describe: 

•	 Data were standardized for gender, race, and education level to represent th

population. Analyses were performed separately by age group because of ininsurance coverage based on Medicare eligibility. Statistical significance wa

•	 Contingency tables and single-predictor, logistic regression models assesse

between the dependent variable, current CRC screening status, and each pvariable. 

•	 For each age group, a multiple logistic regression model was fit using indepe

demonstrated a bivariate association of P < 0.10. 

ASSESSMENT OF EXPOSURES AND Variables included:
 

POTENTIAL CONFOUNDERS: • Demographic (gender, race, education, ethnicity – Hispanic only, employme

•	 Health factors (family history of CRC, health status) 

•	 Access (income, insurance, regular MD, gets regular checkups, frequency o

FOBT card, MD recommendation) 

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OUTCOME ASSESSMENT: Outcome Measures: 

•	 Items asked about testing for FSIG, colonoscopy, BE, and FOBT, including 

returned (FOBT) and those done in a physician’s office (FOBT/MD). 

•	 A broad definition of CRC screening status included colonoscopy or BE (scr

10 years, FSIG within 5 years, and FOBT in the past year as options 

Secondary Outcomes: Insurance and health service characteristics by age and CRC screening. 

RESULTS: KQ2 - What factors influence the use of colorectal cancer screening? 

Outcomes: Significant predictors of CRC screening for younger group (age 50-64): marital status (P = CRC (P = 0.032), perceived health status (P = 0.015); for older group (age 65+): income 

Among the younger group, those in plans that subjects believed did not cover CRC screeand those with Medicare or Medicaid had the highest (P < 0.0001). Among participants wiwith HMO coverage had a slightly higher rate (59.1%) than non-HMO respondents (55.3%older group also varied substantially by insurance coverage, but did not reach statistical smembers were most likely to be currently tested. Respondents who reported that their plans covered FOBT, FSIG, and/or colonoscopy werbeing currently tested (P < 0.0001). Having a regular physician and receiving a regular checkup were significantly related to c
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

STUDY:	 Authors, ref ID: Zapka et al.67 

Year of publication: Dates of data collection: 2002 Trial name: NA 

C-245
 

Provider recommendations (P < 0.0001) and getting a regular checkup (P < 0.0001) were 

screening status. M.D. ever rec. Sigmoidoscopy, Age 50-64 from total sample: NO: N, 175; %, 33.8; YES: N, 342; %, 66.2; 

Age 50-64 from *currently tested sample: NO: N, 151; %, 86.3; YES: N, 118; %, 34.5 P <0.0001 Age ≥ 65from total sample: NO: N, 203; %, 42.5; YES: N, 274; %, 57.5; 

Age ≥ 65from currently tested sample: NO: N, 181; %, 89.5; YES: N, 111; %, 40.5 

P <0.0001 *Currently tested: up to date 

KQ3 - Which strategies are effective in Outcomes: 

increasing the appropriate use of NA colorectal cancer screening and
 followup?
 KQ4 - What are the current and Outcomes: projected capacities to deliver NA colorectal cancer screening and
 surveillance at the population level? KQ5 - What are the effective approaches Outcomes: for monitoring the use and quality of NA colorectal cancer screening? QUALITY RATING: Fair 
Evidence Table 1. KQ 2: What factors influence the use of colorectal cancer screening (continued) 

Quality Assessment-Internal Validity for Observational Studies 

Yes No Othe

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Were the groups similar at baseline regarding the most important X ( Different age groups prognostic indicators? had different 

characteristics) 

Were the drop-out or response rates acceptable (≤ 20%)? [If between 20% 64%, 

and 60%, check other and explain.] surve

reaso

Were the differential drop-out or response rates acceptable (≤ 15%)? N/A Were intervention/exposure measures valid, reliable, and equally applied? N/A Were the outcome assessors blinded to the intervention or exposure N/A status of subjects? Were outcome measures valid, reliable, and equally applied? X Does the analysis control for baseline differences? X Were important potential confounding and modifying variables taken into X 

account in the design and analysis (e.g., through matching, stratification, or statistical adjustment)? Were the statistical methods used to assess the abstracted outcomes X appropriate? Quality Rating (Good, Fair, or Poor): Fair
 

Reviewer #1 initials: BLM
 Reviewer #2 initials: Comments (explain poor quality ratings): 
C-247 

Evidence Table 2. KQ 3: Which strategies are effective in increasing the appropriate use of colorectal cancer screening and suSTUDY:	 Authors, ref ID: Ayanian, J.Z., Sequist, T.D., Zaslavsky, A.M., Johannes R.S.68 

Year of publication: 2008 Dates of data collection: May 1 – October 31, 2006 Trial name: 

OBJECTIVE OR AIM: To determine whether surveillance colonoscopy can be increased among overdue patients by re

physicians. 

DESIGN: Setting: Clinics in Massachusetts primary care networks 

Study design: Randomized controlled trial Duration (mean followup): 6 months Overall study size (N enrolled/N analyzed): 

INTERVENTIONS: Intervention Control 

Sample size: Sample size = 358 Sample size = 359 

Intervention: Sent letter to physicians to notify them about Intervention: After 6-month obse

Describe intervention: potential need for colonoscopy among their patients in identical mailing was sent to phy

intervention group. Included a personally addressed letter to control group to ensure their phyeach patient recommending colonoscopy and encouraging potential need for colonoscopy if them to call their physician’s office to schedule procedure. If physicians felt colonoscopy was clinically indicated they could send these letters. Physicians who did not respond to initial letter within 1 month were sent a second cover letter, response form, and reminder letters addressed to their patients. 

RECRUITMENT: • Clinic-based; Physicians from 2 Massachusetts primary care networks were inform

(population-based, clinic-based, participation in study was voluntary and confidential. volunteer, other) • Patients who had colorectal polyps removed via flexible sigmoidoscopy or colonosc

through 2000 were ascertained from electronic endoscopy database maintained by gastroenterology division. 

INCLUSION CRITERIA:	 Patients had 1 or more adenomas detected by colonoscopy at Brigham and Women’s Hospital f

did not have a follow-up colonoscopy documented in electronic clinical data during 2001 through an active attending physician in a primary care practice affiliated with Brigham and Women’s HoVanguard Medical Associates. 

EXCLUSION CRITERIA:	 Did not have an adenoma on pathology report from initial colonoscopy, had subsequent colonos

records of integrated practice, patient who did not have an active primary physician listed in elec

POPULATION Group 1 Group 2 CHARACTERISTICS: 

Mean age: 69.2 Mean age: 69.2 

Mean age & range (years): 62.3% 65 years or older 63% 65 years or older 

Sex (% female): 45% female 47.6% female 

Race: Mean years since colonoscopy: 6.7 Mean years since colonoscopy: 6.6 Other population qualities: 
Evidence Table 2. KQ 3: Which strategies are effective in increasing the appropriate use of colorectal cancer screening and su

STUDY:	 Authors, ref ID: Ayanian, J.Z., Sequist, T.D., Zaslavsky, A.M., Johannes R.S.68 

Year of publication: 2008 Dates of data collection: May 1 – October 31, 2006 Trial name: 

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Group 1 Group 2 

Attrition/Drop-out (not available for endpoint measurement): NA Adherence in control group: Contamination in control group: OUTCOME ASSESSMENT: Outcome Measures: 

The primary study outcome was proportion of patients receiving colonoscopy during 6-month obintervention and control groups A response form was included in mailings to physicians, asking them to report whether they intenletter or call each of their patients in intervention group to recommend colonoscopy. They were a

patient should not have this procedure (deceased, severe comorbid illness, advanced age, had fsince 2000, or no longer active in physician’s practice). 

RESULTS: 

KQ2 - What factors influence use Outcomes: of colorectal cancer screening? NA KQ3 - Which strategies are Outcomes: effective in increasing appropriate Patients whose physicians received reminders 9.2% patients underwent colonoscopy within 6 muse of colorectal cancer 4.5% of patients whose physicians did not receive reminders (P = 0.009). screening and followup? In prespecified subgroups, this effect did not differ statistically between 2 primary care networks, 

patients, or women and men (all P > 0.60 by Breslow–Day test). 

KQ4 - What are current and Outcomes: projected capacities to deliver NA colorectal cancer screening and surveillance at population level? KQ5 - What are effective Outcomes: approaches for monitoring use NA and quality of colorectal cancer screening? QUALITY RATING: Good 
Evidence Table 2. KQ 3: Which strategies are effective in increasing the appropriate use of colorectal cancer screening and su

Quality Assessment-Internal Validity for Controlled Trials Was study described as randomized? Was method of randomization adequate? Was treatment allocation concealed? 

Yes X X 

No 

X 

Were groups similar at baseline regarding most important prognostic indicators? Was outcome assessor blinded? 

X 

X 

Was care provider blinded?Was patient blinded? X 

X 

Was drop-out rate acceptable (≤ 20%)? [If between 20% and 60%, check other and explain.] Was differential drop-out rate acceptable (≤ 15%)?

Were co-interventions avoided or similar? X 

 

Were outcome measures valid, reliable, and equally applied? Were all randomized participants analyzed in group to which they were originally assigned? Quality Rating (Good, Fair, or Poor): Good 

X 

X 

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Evidence Table 2. KQ 3: Which strategies are effective in increasing the appropriate use of colorectal cancer screening and su

Evidence Table XX Title 

C-250
 

STUDY: Authors, ref ID: Basch, CE, Wolf, RL, Brouse, CH, Shmukier, C, Neugut, A, DeCarlo, LT

Year of publication: 2006 Dates of data collection: 2000 - 2003 Trial name: NA 

OBJECTIVE OR AIM: •	 Authors compared effectiveness of a telephone outreach approach versus a direct ma

rates of colorectal cancer (CRC) screening in a predominantly Black population 

DESIGN: Setting: New York City. Sampling frame from membership lists of a health benefit fund co

250,000 members. Through this benefit fund, all individuals had health insurance coveragfor CRC screening. Study design: RCT Duration (mean followup): Medical records reviewed 6 months after randomization Overall study size (N enrolled/N analyzed): 456/456 

INTERVENTIONS: Intervention (telephone) Con

Sample size: N=226 Describe intervention: Tailored telephone outreach by a health educator to include Printed materials o

establishing a positive and trusting rapport with recipient; reinforcing participants into staccurate knowledge and healthful beliefs, correcting brochure. misconceptions, and bolstering self-efficacy to obtain a CRC screening on basis of participant’s readiness and individual cognitive factors; addressing identified barriers (e.g., fear, transportation) and skill deficits that could impede CRC screening; providing social and emotional support for obtaining CRC screening; and eliciting a verbal commitment to obtain CRC screening. Median number of intervention calls was 5, and median number of total telephone minutes spent per participant was 23.5. 

RECRUITMENT: Telephone recruitment among those in health plan, eligibility assessed by telephone. 

(population-based, clinic-based, volunteer, or) INCLUSION CRITERIA: Inclusion criteria were age greater than 52 years, no self-report of a recent CRC screening 

test within past 2 years, a flexible sigmoidoscopy within past 5 years, or colonoscopy or byears), no scheduled appointment for a CRC screening test, accessibility by telephone, abprimary care physician (PCP), and consent to participate 

EXCLUSION CRITERIA:	 Exclusion criteria included self-report of prior diagnosis of colorectal polyps, inflammatory 

other cancer that had been treated within past 5 years; stated intention to travel or to mov

subsequent 6 months; unemployed, retired, or unable to work due to disability; enrollment household into study; or another medical condition that precluded meaningful participation 
Evidence Table 2. KQ 3: Which strategies are effective in increasing the appropriate use of colorectal cancer screening and su

STUDY: Authors, ref ID: Basch, CE, Wolf, RL, Brouse, CH, Shmukier, C, Neugut, A, DeCarlo, LT

Year of publication: 2006 Dates of data collection: 2000 - 2003 Trial name: NA 

POPULATION CHARACTERISTICS: Mean Age Age 52-54 55-59 

 >=60 Sex (% female): Race: Black  White Or  Refused Education: < H.S. H.S. grad  Some college/tech school 

C-251 College or beyond 
 Attrition/Drop-out (not available for 

endpoint measurement): Adherence in control group: Contamination in control group: 

Intervention (n=226) 

19.5% (n=44) 

47.8% (n=108) 

32.7% (n=74) 

69.9% (n=158) 67.7% (n=153) 

13.7% (n=31) 17.7% (n=40) 

0.9% (n=2) 

11.9% (n=27) 

46.0% (n=104) 

31.9% (n=72) 10.2% (n=23) 

Intervention 

Telephone intervention was implemented (1 or more calls completed) in 216 of 226 (95.6%) of those assigned to intervention. 10 intervention participants refused participation after randomization 

Control (n=230) 

25.7% (n=59) 

43.5% (n=100) 

30.9% (n=71) 

72.2% (n=166) 58.7% (n=135) 

18.7% (n=43) 21.7% (n=50) 

0.9% (n=2) 

7.8% (n=18) 

40.4% (n=93) 38.7% (n=89) 12.6% (n=29) 

Screened (n=61) 

57.5y (sd 3.4) 

67.2% (n=41) 72.1% (n=44) 

11.5% (n=7) 

15.4% (n=10) 

11.5% (n=7) 

42.6% (n=26) 34.4% (n=21) 

11.5% (n=7) 

Group 2	 O

OUTCOME ASSESSMENT: Primary outcome was receipt of CRC screening within 6 months of randomization. Outcom

receipt of a 3-day fecal occult blood test (defined as 2 samples from each of 3 consecutive sigmoidoscopy, colonoscopy, or a barium enema. A single stool test (defined as a single sand tested for occult blood during a medical examination) was not considered an acceptaoutcome. 

Results KQ2 - What factors influence use of NA colorectal cancer screening? KQ3 - Which strategies are effective in CRC screening was documented in 61 of 226 (27%) in G1 and 14 of 230 (6.1%) in G2 (20increasing appropriate use of colorectal difference). Compared with G2, those in G1 were 4.4 times more likely to receive CRC sccancer screening and followup? randomization (AOR, 6.38; 95% CI: 3.44-11.85). QUALITY RATING: Good 
Evidence Table 2. KQ 3: Which strategies are effective in increasing the appropriate use of colorectal cancer screening and su

Quality Assessment-Internal Validity (for RCT) 

Yes No 

Was study described as randomized? x Was method of randomization adequate? x Was treatment allocation concealed? x Were groups similar at baseline regarding most important prognostic indicators? x Was outcome assessor blinded? x Was care provider blinded? x Was patient blinded? 

x 

Was drop-out rate acceptable? x Was differential drop-out rate acceptable? x Were co-interventions avoided or similar? x Were outcome measures valid, reliable, and equally applied? x Were all randomized participants analyzed in group to which y were originally assigned? x Quality Rating: Good 

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Evidence Table 2. KQ 3: Which strategies are effective in increasing the appropriate use of colorectal cancer screening and su

STUDY:	 Authors, ref ID: Braun, K.L., Fong, M., Kaanoi, M.E., Kamaka, M.L., Gotay, C.C.69 

Year of publication: 2005 Dates of data collection: January 2003 to May 2003 Trial name: NA 

OBJECTIVE OR AIM: Test CRC screening interventions for Native Hawaiians. 

DESIGN: Setting: Hawaiian civic clubs 

Study design: Randomized trial Duration (mean followup): No results were collected after 16 weeks post-intervention. Overall study size (N enrolled/N analyzed): 121 people 

INTERVENTIONS: Sample size: Describe intervention: 

Experimental 

Sample size: 69 Intervention: Native Hawaiian physician delivered the targeted educational Presentation; Native Hawaiian CRC survivor told his personal story, addressing myths and feelings of embarrassment related to CRC screening and communicating positive feelings associated with self-care and survivorship; free FOBT kits, Native Hawaiian physician provided instructions on testing and demonstrated how to use the FOBT kit to collect stool samples. Multiple telephone calls were placed to those who did not complete their FOBT 4 to 16 weeks post intervention 

Contr

Sample size: 52 Intervention: Targeted educatioHawaiian nurse; brochure on CR

Hawaiian nurse; FOBT kit; nurse about completing FOBT kit; telenot returned within a month. 

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RECRUITMENT: Civic centers; 16 of the 39 Hawaii based clubs volunteered to participate
 (population-based, clinic-based, volunteer, other) INCLUSION CRITERIA: Age 50+
 EXCLUSION CRITERIA: NR POPULATION CHARACTERISTICS: Experimental	 Contr

Mean age: 65.68 Mean age: 65.77 

Mean age & range (years): Sex: 70% female Sex: 75% female 

Sex (% female): Ethnicity: 90% Hawaiian, 10% Non-Hawaiian Ethnicity: 90% Hawaiian, 10% NRace: Other population qualities: 

Experimental Contr

Attrition/Drop-out (not available for 95% data-completion rate 95% data-completion rate endpoint measurement): Adherence in control group: Contamination in control group: OUTCOME ASSESSMENT: Outcome Measures: 

FOBTs returned 

RESULTS: 
Evidence Table 2. KQ 3: Which strategies are effective in increasing the appropriate use of colorectal cancer screening and su

STUDY:	 Authors, ref ID: Braun, K.L., Fong, M., Kaanoi, M.E., Kamaka, M.L., Gotay, C.C.69 

Year of publication: 2005 Dates of data collection: January 2003 to May 2003 Trial name: NA 

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KQ2 - What factors influence the use of NA colorectal cancer screening?
 KQ3 - Which strategies are effective in Outcomes: increasing the appropriate use of • 33% of the experimental group (n=23) completed the free FOBT, compacolorectal cancer screening and control group (no p-value given). followup? • 13 were screened for 1st time (5 in experimental and 8 in control) 

• People in the intervention group were less likely to be screened than people in the co

percentage points; 95% CI, 14.34-27.46 percentage points); RR 4.4 (2.6-7.7) 

KQ4 - What are the current and NA projected capacities to deliver colorectal cancer screening and surveillance at the population level? KQ5 - What are the effective approaches NA for monitoring the use and quality of colorectal cancer screening? QUALITY RATING: Fair Quality Assessment-Internal Validity for Controlled Trials 

Yes No Other (CD, NR, N

Was the study described as randomized? X Was the method of randomization adequate? X Was the treatment allocation concealed? X Were the groups similar at baseline regarding the most important prognostic indicators? Was the outcome assessor blinded? 

X 

NR 

Was the care provider blinded? Was the patient blinded?Was the drop-out rate acceptable (≤ 20%)? [If between 20% and 60%, check other and explain.] Was the differential drop-out rate acceptable (≤ 15%)? 

Were co-interventions avoided or similar? 

X 

X 

X 

NA 

Actually, only a 50

final questionnaire 

Were outcome measures valid, reliable, and equally applied? Were all randomized participants analyzed in the group to which they were originally assigned? Quality Rating (Good, Fair, or Poor): Fair 

X 

X Only the experime

measured on whekit for family mem
Evidence Table 2. KQ 3: Which strategies are effective in increasing the appropriate use of colorectal cancer screening and su

STUDY:	 Authors, ref ID: Campbell, MK, James, A, Hudson, MA, Carr, C, Jackson, E, Oates, V, D

Year of publication: 2004 Dates of data collection: 1999-2000? Trial name: WATCH 

OBJECTIVE OR AIM: To compare the effectiveness of 2 strategies to promote multiple health behaviors includin

preventive behaviors among African American members of 12 rural North Carolina church

DESIGN: Setting: Churches in rural NC 

Study design: RCT Duration (mean followup): 1 year Overall study size (N enrolled/N analyzed): 587 individuals, 12 churches 

INTERVENTIONS: G1: TPV G2: LHA G3: Combined 

Sample size: Describe intervention: 

Sample size: 76 (50 years or older) Intervention: included four 

Sample size: 51 (50 years or older) Intervention: Church members 

Sample size: 87 (5years or older) Intervention: Both 

personalized computer- who volunteered were invited to a TPV and LHA 

tailored newsletters and four reception and orientation to interventions 

targeted videotapes participate in the LHA training corresponding to the same program. A total of seven monthly behaviors mailed to or bimonthly group training participants’ homes bimonthly sessions (approximately 16 hr of for the first 6 months after training) were scheduled at baseline data collection respective churches at times (Months 2, 4, and 6); the chosen by the LHAs. Each trained fourth mailing occurred 9 LHA was required to identify up to months postbaseline. 3 specific church-wide activities 

where they could spread the word about the intervention. 

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RECRUITMENT: Population-based; members of 12 African American churches in five rural eastern North C(population-based, clinic-based, volunteer, other) INCLUSION CRITERIA: Medically incapable of participation, less than 18 years old EXCLUSION CRITERIA: NR POPULATION CHARACTERISTICS: (NOTE: Of total sample, not just those 50 years or older)
 Mean age & range (years): Sex (% female): Race: Other population qualities:
 

Control 

Sex: 77.3% female Age: 21.1% <40, 26.6% 40-49,
 52.3% 50+
 

LHA
 

Sex: 72.4% female Age: 21.1% <40, 37.5% 40-49, 41.4% 50+
 

TPV
 

Sex: 73.6% female Age: 30.1% <40, 22.7% 40-49, 47.2% 50+
 

All 

Attrition/Drop-out (not available for 10 of 26 eligible churches endpoint measurement): participated (38%) 
Evidence Table 2. KQ 3: Which strategies are effective in increasing the appropriate use of colorectal cancer screening and su

STUDY:	 Authors, ref ID: Campbell, MK, James, A, Hudson, MA, Carr, C, Jackson, E, Oates, V, D

Year of publication: 2004 Dates of data collection: 1999-2000? Trial name: WATCH 

Adherence in control group: 58% of eligible people completed Contamination in control group: baseline survey 

CASRO response rate = 66% 

OUTCOME ASSESSMENT: Outcome Measures: 

•	 Baseline telephone interviews were conducted before randomization. 

•	 Participants were asked whether they had ever had any CRC screening test

(< 1 year, 1–2 years, 2–5 years, or > 5 years). 

•	 From these items, authors computed two variables indicating compliance wi

in the past year and any combination of tests indicating up-to-date adherenc(FOBT in the past year plus or minus sigmoidoscopy in the past 5 years, doin the past 5 years, or colonoscopy in the past 5 years). 

RESULTS: KQ2 - What factors influence the use of NA colorectal cancer screening? 

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KQ3 - Which strategies are effective in increasing the appropriate use of colorectal cancer screening and followup? 

Outcomes: G1: 36.8% received FOBT test; 21.1% received another CRC test G2: 33.3% received FOBT test; 25.5% received another CRC test G3: 31.0% received FOBT test; 14.9% received another CRC test G4: 21.7% received FOBT test; 27.5% received another CRC test 

•	 Differences in group are not statistically significant (p=0.08 for FOBT, NR for ‘other’ te

of other screening tests did not differ among study groups at baseline or follow-up. 

KQ4 - What are the current and NA projected capacities to deliver colorectal cancer screening and surveillance at the population level? KQ5 - What are the effective approaches NA for monitoring the use and quality of colorectal cancer screening? QUALITY RATING: Fair 
Evidence Table 2. KQ 3: Which strategies are effective in increasing the appropriate use of colorectal cancer screening and su

Quality Assessment-Internal Validity for Controlled Trials Was the study described as randomized? 

Yes 

X 

No Other (CD, NR, NA) 

Was the method of randomization adequate? X Was the treatment allocation concealed? X Were the groups similar at baseline regarding the most 

X 

important prognostic indicators? Was the outcome assessor blinded? X Was the care provider blinded? X Was the patient blinded? X Was the drop-out rate acceptable (≤ 20%)? [If between 20% CD and 60%, check other and explain.] Was the differential drop-out rate acceptable (≤ 15%)? CD 

Were co-interventions avoided or similar? X Were outcome measures valid, reliable, and equally applied? X Were all randomized participants analyzed in the group to 

X 

which they were originally assigned? Quality Rating (Good, Fair, or Poor): Fair 

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Evidence Table 2. KQ 3: Which strategies are effective in increasing the appropriate use of colorectal cancer screening and su

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STUDY:	 Authors, ref ID: Church, T.R., Yeazel, M.W., Jones, R.M, Kochevar, L.K, Watt, G.D., Mo

Engelhard, D. 71 

Year of publication: 2004 Dates of data collection: February 2000 to March 2001 Trial name: 

OBJECTIVE OR AIM: Test whether direct mailing of FOBT kits with and without reminders to a general populatio

cancer screening. 

DESIGN: Setting: Mailed questionnaires and FOBT kits to study participants’home 

Study design: Randomized trial Duration (mean followup): 1 year Overall study size (N enrolled/N analyzed): 1255 baseline, 1144 1 year follow-p 

INTERVENTIONS: Reminders No Reminders Sample size: Sample Size: 404 baseline, 351 1 Sample Size: 434 baseline, 390 1 Sample Si

year year year 

Describe intervention: Intervention: questionnaire, FOBT Intervention: questionnaire, FOBT kits Interventio

kits with mailed reminders with no reminders 

RECRUITMENT: Minnesota State Driver’s License and Identification Card database (population-based, clinic-based, volunteer, other) INCLUSION CRITERIA:	 at least 50 years old and had a mailing address with a ZIP code that included some part o

1, 2000 

EXCLUSION CRITERIA: POPULATION CHARACTERISTICS: Reminders No Reminders 

Mean age: 63.4 baseline, 63.1 year Mean age: 63.1 baseline, 62.6 year Mean age

Mean age & range (years): Sex (% female): Race: 

1 Sex: 55.9% female baseline; 56.4% 1 year 

1 Sex: 52.5% female baseline, 53.6% 1 year 

1 Sex: 51.81 year 

Other population qualities: 

Reminders No Reminders 

Attrition/Drop-out (not available for endpoint measurement): Adherence in control group: Contamination in control group: OUTCOME ASSESSMENT: 

84.1% response rate baseline, 76.5% year 1 

Outcome Measures: 

89% response rate baseline, 83.3% year 1 

86.4% res86.1% ye

The primary outcome of the study was the change in overall self-reported adherence to sc

RESULTS: KQ2 - What factors influence the use of Outcomes: colorectal cancer screening? NA 
Evidence Table 2. KQ 3: Which strategies are effective in increasing the appropriate use of colorectal cancer screening and su

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STUDY:	 Authors, ref ID: Church, T.R., Yeazel, M.W., Jones, R.M, Kochevar, L.K, Watt, G.D., Mo

Engelhard, D. 71 

Year of publication: 2004 Dates of data collection: February 2000 to March 2001 Trial name: 

KQ3 - Which strategies are effective in Outcomes: 

increasing the appropriate use of • The 1-year rate changes for self-reported adherence to FOBT use were 1.5% colorectal cancer screening and for the control group, 16.9% (95% CI : 11.5% to 22.3%) for the group receivfollowup? no reminders, and 23.2% (95% CI:17.2% to 29.3%) for the group receiving d

reminders. 

•	 The 1-year rate changes for self-reported adherence to any colorectal c

7.8% (95% CI: 3.2% to 12.0%) for the control group, 13.2% (95% CI: 8.4% treceiving direct mail FOBT with no reminders, and 14.1% (95% CI: 9.1% to receiving direct mail FOBT with reminders. 

•	 Self-reported adherence to guidelines for FOBT increased 18.4% more 

in the direct mail group than in the control group; overall self-reported adherof the colorectal cancer screening tests increased 5.9% more (95% CI: 0.5% mail group than in the control group. 

•	 By contrast, the differences in the 1-year rate change between the FOB

versus the FOBT-with-noreminders group were smaller and not statistically s

KQ4 - What are the current and Outcomes: projected capacities to deliver colorectal NA cancer screening and surveillance at the population level? KQ5 - What are the effective approaches Outcomes: for monitoring the use and quality of NA colorectal cancer screening?
 QUALITY RATING: Fair 
Evidence Table 2. KQ 3: Which strategies are effective in increasing the appropriate use of colorectal cancer screening and su

Quality Assessment-Internal Validity for Controlled Trials Was the study described as randomized? 

Yes X 

No 

Was the method of randomization adequate?

 NR 

Was the treatment allocation concealed? 

X 

Were the groups similar at baseline regarding the most important prognostic indicators? Was the outcome assessor blinded? 

X 

 

Was the care provider blinded?Was the patient blinded? Was the drop-out rate acceptable (≤ 20%)? [If between 20% and 60%, check other and explain.] Was the differential drop-out rate acceptable (≤ 15%)? 

Were co-interventions avoided or similar? 

X 

X 

X 

X  

Were outcome measures valid, reliable, and equally applied? Were all randomized participants analyzed in the group to which they were originally assigned? Quality Rating (Good, Fair, or Poor): Fair 

X 

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Evidence Table 2. KQ 3: Which strategies are effective in increasing the appropriate use of colorectal cancer screening and su

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STUDY:	 Authors, ref ID: Costanza, M.E., Luckmann, R., Stoddard, A.M., White, M.J., Stark, J.R.

Clemow, L.72 

Year of publication: 2007 Dates of data collection: 2001-2004 Trial name: 

OBJECTIVE OR AIM: This study’s purpose was to implement and evaluate stage-based computer-assisted tailo

to promote colorectal cancer screening in a primary care population. 

DESIGN: Setting: Practices of community-based PCPs in the UMass Health Care system (UMHC) 

Study design: Randomized controlled trial Duration (mean followup): 3 months Overall study size (N enrolled/N analyzed): 51 active office-based PCPs; 2,448 patients 

INTERVENTIONS: Intervention Control Sample size: Sample Size: 1187 records audited Sample size: 1261 records audited Describe intervention: Intervention: mailed booklet on Regular care 

colorectal cancer screening followed by computer-assisted telephone counseling that was based on the Precaution Adoption Process Model three months later 

RECRUITMENT: Clinic-based; patients of PCPs in the UMass Health Care system 

(population-based, clinic-based, volunteer, other) INCLUSION CRITERIA:	 Patients were between 50 and 75 years old, had documentation of a visit to a study practi

years and no record of a colonoscopy within the prior 10 years 

EXCLUSION CRITERIA:	 Patients with a limited life expectancy, cognitive impairment, a history of CRC or adenoma

disease requiring frequent screening or non-English speakers 

POPULATION CHARACTERISTICS:	 All 

Mean age & range (years): Mean age: 61.4 years, between 50­Sex (% female): 75 years Race: 57% female Other population qualities: 92% non-Hispanic white 

Group 1 Group 2 

Attrition/Drop-out (not available for NA endpoint measurement): Adherence in control group: Contamination in control group: 
Evidence Table 2. KQ 3: Which strategies are effective in increasing the appropriate use of colorectal cancer screening and su

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STUDY:	 Authors, ref ID: Costanza, M.E., Luckmann, R., Stoddard, A.M., White, M.J., Stark, J.R.

Clemow, L.72 

Year of publication: 2007 Dates of data collection: 2001-2004 Trial name: 

OUTCOME ASSESSMENT: Outcome Measures: 

•	 Chart audit was used to document completion of colonoscopy, sigmoido

testing; completed between 17 and 22 months after a subject’s baseline sur

• Patients were coded as having a test in the post-TCC period if the test d

•	 months after the mailing of the brochure. Patients were coded as having a te

period if the test date was within three months following the mailing of the br

•	 For each test authors coded patients as up-to-date with the test if the m

test within the recommended period. If there was no indication of a test in thcoded as not up-to-date. 

RESULTS: KQ2 - What factors influence the use of Outcomes: 

colorectal cancer screening? NA KQ3 - Which strategies are effective in G1: 25% completed any CRC test increasing the appropriate use of G2: 24% completed any CRC test (P = 0.68) colorectal cancer screening and
 followup?
 KQ4 - What are the current and Outcomes: projected capacities to deliver colorectal NA cancer screening and surveillance at the population level? KQ5 - What are the effective approaches Outcomes: for monitoring the use and quality of NA colorectal cancer screening?
 QUALITY RATING: Fair 
Evidence Table 2. KQ 3: Which strategies are effective in increasing the appropriate use of colorectal cancer screening and su

Quality Assessment-Internal Validity for Controlled Trials Was the study described as randomized? 

Yes X 

No 

Was the method of randomization adequate? Was the treatment allocation concealed? Were the groups similar at baseline regarding the most important prognostic indicators? X Was the outcome assessor blinded? Was the care provider blinded? Was the patient blinded? Was the drop-out rate acceptable (≤ 20%)? [If between 20% and 60%, check other and explain.] Was the differential drop-out rate acceptable (≤ 15%)? 

Were co-interventions avoided or similar? X 

Were outcome measures valid, reliable, and equally applied? Were all randomized participants analyzed in the group to which they were originally assigned? Quality Rating (Good, Fair, or Poor): Fair 

X 

X 

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Evidence Table 2. KQ 3: Which strategies are effective in increasing the appropriate use of colorectal cancer screening and suSTUDY: Authors, ref ID: Denberg, TD, Coombes, JM, Byers, TE, Marcus, AC, Feinberg, LE, Stein

Year of publication: 2006 Dates of data collection: pt enrollment in 2005 Trial name: NA 

OBJECTIVE OR AIM: Test whether a mailed brochure after referral for screening colonoscopy will lead to a 10% 

completion compared to those receiving usual care 

DESIGN: Setting: 2 general internal medicine practices affiliated with University of Colorado Health 

Study design: randomized controlled trial Duration (mean followup): hospital claims record reviewed 4 months after referral to det

completed Overall study size (N enrolled/N analyzed): 781 consecutive patients enrolled. 25 duplic

who had received more than 1 c-scope referral. 

INTERVENTIONS: No Mailer (control) Mailer (intervention) Sample size: 395 386 Describe intervention: “usual care” Brochure was mailed within 10 days 

of referral for screening colonoscopy; it mentioned name of patient’s primary care physician and encouraged patients to schedule a procedure. Also described colorectal cancer and polyps and similar lifetime risks for colorectal cancer for men and women, colonoscopy and risk for perforation, nature of bowel preparation for procedure, and alternative screening tests. 

RECRUITMENT: 2 General Internal Medicine practices associated with University of Colorado Health Scien(population-based, clinic-based, patients recruited volunteer, other) INCLUSION CRITERIA: Authors included asymptomatic men and women 50 years of age and older who received 

colonoscopy. 

EXCLUSION CRITERIA: Patients referred because of gastrointestinal symptoms, iron-deficiency anemia, positive f

results, or any other diagnostic purpose were excluded. 
Evidence Table 2. KQ 3: Which strategies are effective in increasing the appropriate use of colorectal cancer screening and su

STUDY: Authors, ref ID: Denberg, TD, Coombes, JM, Byers, TE, Marcus, AC, Feinberg, LE, Stein

Year of publication: 2006 Dates of data collection: pt enrollment in 2005 Trial name: NA 

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POPULATION CHARACTERISTICS: No mailer (control)	 Mailer (intervention) 

Mean age & range (years): 

 50-64y >=65y 75.7% (n=299) 78.5% (n=303) 

Sex (% female): 24.3% (n=96) 21.5% (n=83) 

Race: 62.5% (n=148) 61.1% (n=236) 

 White, non-Latino  Black, non-Latino 53.7% (n=212) 59.6% (n=230) 

 Latino 10.1% (n=40) 7.0% (n=27) 

 Other or unknown 3.8% (n=15) 4.2% (n=16) 

32.4% (n=128)	 29.3% (n=113) 

Marital status 

 Not married Married 29.4% (n=116) 29.5% (n=114)  Unknown	 58.0% (n=229) 58.0% (n=224)
 

12.7% (n=50) 12.4% (n=48) 

Group 1 Intervention 

Attrition/Drop-out (not available for 2 mailers returned as undeliverable endpoint measurement): Adherence in control group: No attrition, since medical record Contamination in control group: claims were reviewed after mailing OUTCOME ASSESSMENT: 

Outcome Measures: Medical claims examined at 4 months to see if a record had been generated. If yes, c-scorecord, recorded as not completed. Pt demographics obtained from medical record, cross-referenced with medical record numBlinded manual review of claims data was unnecessary because the primary outcome waand tabulation of electronic claims generated within 4 months of patient enrollment. 

Results KQ2 - What factors influence the use of NA colorectal cancer screening? KQ3 - Which strategies are effective in Receiving a mailer was associated with a rate of colonoscopy completion that was 11.7 p

increasing the appropriate use of 5.1 to 18.4 percentage points) greater than that seen with usual care (70.7% vs. 59.0%, recolorectal cancer screening and
 followup?
 QUALITY RATING: Fair Quality Assessment-Internal Validity 
Evidence Table 2. KQ 3: Which strategies are effective in increasing the appropriate use of colorectal cancer screening and su

Was the study described as randomized? Was the method of randomization adequate? Was the treatment allocation concealed? 

Yes x 

x 

No 

x 

Were the groups similar at baseline regarding the most important prognostic indicators? Was the outcome assessor blinded? 

x 

x 

Was the care provider blinded?Was the patient blinded?Was the drop-out rate acceptable? Was the differential drop-out rate acceptable? Were co-interventions avoided or similar? 

x 

x 

x x x 

Were outcome measures valid, reliable, and equally applied? x Were all randomized participants analyzed in the group to which they were originally assigned? Quality Rating: Fair 

x 

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Evidence Table 2. KQ 3: Which strategies are effective in increasing the appropriate use of colorectal cancer screening and su

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STUDY:	 Authors, ref ID: Dietrich AJ, Tobin JN, Cassells A, Robinson CM, Greene MA, Sox CH, 

Younge RG74 

Year of publication: 2006 Dates of data collection: November 2001 to April 2004 Trial name: NA 

OBJECTIVE OR AIM: To evaluate the effect of a telephone support intervention to increase rates of breast, cerv

screening among minority and low-income women. 

DESIGN: Setting: 11 community and migrant health centers in New York City 

Study design: Randomized controlled trial Duration (mean followup): 18 months Overall study size (N enrolled/N analyzed): 707 in control, 706 in intervention 

INTERVENTIONS: Control Intervention 

Sample size: Sample size: 707 Sample size: 706 

Intervention: Usual care Intervention: Over 18 months, women 

Describe intervention: assigned to the intervention group 

received an average of 4 calls from prevention care managers (PCM). PCM worked with patients to address barriers, including providing motivational intervention. Physician recommendations were provided to all patients via letter or in the office. Mailing of FOBT was done but data NR. 

RECRUITMENT: Clinic-based 

(population-based, clinic-based, volunteer, other) INCLUSION CRITERIA:	 Women were 50 to 69 years of age, were overdue for at least 1 cancer screening accordi

records, were patients of the center for at least 6 months, and had no plans to move or chwithin 15 months 

EXCLUSION CRITERIA: Language barriers, up-to-date on all screenings, unresolved abnormal screening, declined POPULATION CHARACTERISTICS: Intervention Control 

Mena age: 58.1 Mean age: 58.1 

Mean age & range (years): 

Sex (% female): Race: Other population qualities:
 

All 

Attrition/Drop-out (not available for 64% consented to participate endpoint measurement): Adherence in control group: Contamination in control group: OUTCOME ASSESSMENT: Outcome Measures: 
Evidence Table 2. KQ 3: Which strategies are effective in increasing the appropriate use of colorectal cancer screening and su

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STUDY:	 Authors, ref ID: Dietrich AJ, Tobin JN, Cassells A, Robinson CM, Greene MA, Sox CH, 

Younge RG74 

Year of publication: 2006 Dates of data collection: November 2001 to April 2004 Trial name: NA 

•	 Medical record documentation of mammography, Papanicolaou testing, 

screening according to U.S. Preventive Services Task Force recommendatio

•	 A woman was also considered up to date for colorectal cancer screening if s

colonoscopy within the past 10 years or a barium enema or sigmoidoscopy w

RESULTS: KQ2 - What factors influence the use of NA 

colorectal cancer screening?
 KQ3 - Which strategies are effective in G1: 63% obtained any CRC test in follow-up period (0.24 point change from baseline) increasing the appropriate use of G2: 50% obtained any CRC test (0.11 point change from baseline) colorectal cancer screening and
 followup? 0.13 point difference between G1 and G2 (95% CI, 0.07-0.19) KQ4 - What are the current and NA projected capacities to deliver colorectal cancer screening and surveillance at the population level? KQ5 - What are the effective approaches NA for monitoring the use and quality of colorectal cancer screening? QUALITY RATING: Fair 
Evidence Table 2. KQ 3: Which strategies are effective in increasing the appropriate use of colorectal cancer screening and su

Quality Assessment-Internal Validity for Controlled Trials 

Ye No Other (CD, NR, Ns 

Was the study described as randomized? Was the method of randomization adequate? Was the treatment allocation concealed? 

X 

X 

X 

Were the groups similar at baseline regarding the most important prognostic indicators? Was the outcome assessor blinded? X Was the care provider blinded?Was the patient blinded?Was the drop-out rate acceptable (≤ 20%)? [If between 20% and 60%, check other and explain.] 

Was the differential drop-out rate acceptable (≤ 15%)? 

Were co-interventions avoided or similar? X 

X X 

X 64% consented to 

NA 

Were outcome measures valid, reliable, and equally applied? Were all randomized participants analyzed in the group to which they were originally assigned? Quality Rating (Good, Fair, or Poor): Fair 

X 

X 

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Evidence Table 2. KQ 3: Which strategies are effective in increasing the appropriate use of colorectal cancer screening and su

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STUDY:	 Authors, ref ID: Dietrich, A.J., Tobin, J.N., Cassells, A., Robinson, C.M., Reh, M., Rome

Beach, M.L.75 Year of publication: 2007 Dates of data collection: May 2005 – March 2006 Trial name: 

OBJECTIVE OR AIM: This study evaluated the impact of a streamlined prevention care management (PCM) del

managed care organization (MMCO), an infrastructure with the potential to sustain this pro

DESIGN: Setting: Medicaid managed care organization (MMCO); New York City 

Study design: Randomized trial Duration (mean followup): Overall study size (N enrolled/N analyzed): 1,316 (626 women 50 years or older) 

INTERVENTIONS: PCM intervention Affinity’s Mammography Ou

Sample size: Sample size: 317 Comparison 

Intervention: received up to 3 scripted telephone Sample size: 309 

Describe intervention: calls to identify and overcome barriers and provide Intervention: received up to 3 scri

support to obtain needed breast, cervical, and encourage participation and schecolorectal cancer-screening tests and provided appointment, remind patient of upscheduling assistance and appointment reminders appointment, and verify that patiefor CRC screening; educational material on breast, $25 gift certificate on confirmation cervical, and CRC screening, providing educational information 

CRC screening; and a brief recomtelephone call to discuss CRC scrprofessional. 

RECRUITMENT: Women were identified through Affinity’s (the MMCO) administrative database 

(population-based, clinic-based, volunteer, other) INCLUSION CRITERIA: Age 40-68; received care at 1 of 6 participating Community Health Centers, had been enr

least 12 months, and were overdue for at least 1 of the targeted cancer-screening tests. 

EXCLUSION CRITERIA: POPULATION CHARACTERISTICS:	 PCM intervention Affinity’s Mammography Ou

Comparison 

Mean age & range (years): Sex (% female): Race: Other population qualities: 

PCM intervention Affinity’s Mammography Ou

Attrition/Drop-out (not available for Comparison endpoint measurement): Adherence in control group: Contamination in control group: 
Evidence Table 2. KQ 3: Which strategies are effective in increasing the appropriate use of colorectal cancer screening and su

STUDY:	 Authors, ref ID: Dietrich, A.J., Tobin, J.N., Cassells, A., Robinson, C.M., Reh, M., Rome

Beach, M.L.75 Year of publication: 2007 Dates of data collection: May 2005 – March 2006 Trial name: 

OUTCOME ASSESSMENT: Outcome Measures: 

•	 Screening status was assessed through MMCO administrative data 

•	 Definitions of up-to-date status were derived from US Preventive Services T

matched Health Plan Employer Data and Information Set (HEDIS) breast anguidelines used to assess the quality of MMCOs. 

•	 Up-to-date screening status for colorectal cancer (limited to women age

home fecal occult blood testing within the past year, sigmoidoscopy or doubwithin 5 years, or colonoscopy within 10 years 

RESULTS: KQ2 - What factors influence the use of Outcomes: colorectal cancer screening? NA 

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KQ3 - Which strategies are effective in increasing the appropriate use of colorectal cancer screening and followup? 

Outcomes: In an intent-to-treat comparison adjusted for baseline screening status, PCM women were be up-to-date for colorectal cancer screening tests at follow-up than women in the compaconfidence interval, 1.03-2.77). Comparison of Up-to-Date Status between Study Groups at Baseline and Follow up (CRC Colorectal Cancer Screening (smaller N reflects that this analysis was done on a subset o

aged 50 years and older) PCM group N = 317 AMOP group N = 309 Adjusted Comparison (only adjusted for baseline screening status): Baseline Up to Date N = 56 (18%) in PCM group, N = 48 (16%) in AMOP group Baseline OR – none reported Follow up Up-to Date N= 103 (32%) in PCM group, N = 78 (25%) in AMOP group Follow up OR – 1.69 (95% CI 1.03 – 2.77), p = .04 

KQ4 - What are the current and NA projected capacities to deliver colorectal cancer screening and surveillance at the population level? KQ5 - What are the effective approaches NA for monitoring the use and quality of colorectal cancer screening? QUALITY RATING: Fair 
Evidence Table 2. KQ 3: Which strategies are effective in increasing the appropriate use of colorectal cancer screening and su

Quality Assessment-Internal Validity for Controlled Trials Was the study described as randomized? 

Yes 

X 

No Other (CD, NR, 

Was the method of randomization adequate? NR Was the treatment allocation concealed? NR Were the groups similar at baseline regarding the most important prognostic indicators? X Was the outcome assessor blinded? X Was the care provider blinded? NR Was the patient blinded? X Was the drop-out rate acceptable (≤ 20%)? [If between 20% and 60%, check other and explain.] X Was the differential drop-out rate acceptable (≤ 15%)? X 

Were co-interventions avoided or similar? X Were outcome measures valid, reliable, and equally applied? X Were all randomized participants analyzed in the group to which they were originally assigned? X Quality Rating (Good, Fair, or Poor): Fair 

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Evidence Table 2. KQ 3: Which strategies are effective in increasing the appropriate use of colorectal cancer screening and su

Authors, ref ID: Dolan, J.G., Frisina, S.76 

STUDY: Year of publication: 2002 

Dates of data collection: NR Trial name: NA To conduct a pilot test of a decision aid designed to help patients choose among currently 

OBJECTIVE OR AIM: colorectal cancer screening tests. 

Setting: Clinic; Rochester, New York 

DESIGN: Study design: Randomized controlled trial 

Duration (mean followup): 2-3 months post-visit Overall study size (N enrolled/N analyzed): 95 

INTERVENTIONS: Sample size: Describe intervention: 

Experimental	 Control 

•	 Sample size: 49 • Sample size: 46 

•	 Intervention: description of colorectal cancer • Intervention: standardized interview 

and the 5 screening tests, patients were preliminary phase and an educatiourged to discuss colorectal cancer preliminary phase consisted of a brscreening with their physician at their colorectal cancer and the purpose upcoming visit. demographic survey, questions reg

cancer screening and whether patifor a particular screening method, a how colorectal cancer screening demade, and a 10-question test of pacolorectal cancer and its prevention 

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Clinic-based; patients at average risk for colon cancer being seen for routine appointments 

RECRUITMENT: practices in Rochester, New York. Most patients were recruited from a suburban practice w

4 additional patients were obtained from an inner city faculty-resident teaching practice 

(population-based, clinic-based, 

volunteer, other) 

At average risk for colorectal cancer (defined as ≥50 years old, a negative family history, an

INCLUSION CRITERIA:	 of inflammatory bowel disease, colorectal cancer, or polyps), spoke English fluently, had no

were not too physically ill to participate, were able to hear conversational level speech, had 

least 3 years, were eligible for a colorectal cancer screening test according to the guideline (i.e., no history of fecal occult blood testing within the past 11 months, flexible sigmoidoscobarium enema within the past 5 years, or colonoscopy within the past 10 years), and were Recent screening, history of polyp, positive family history, too ill, abnormal mental status, h

EXCLUSION CRITERIA:	 history of colorectal cancer, non-compliant or refuses all screening, not fluent enough in En

physician 
Evidence Table 2. KQ 3: Which strategies are effective in increasing the appropriate use of colorectal cancer screening and su

Authors, ref ID: Dolan, J.G., Frisina, S.76 

STUDY: Year of publication: 2002 

Dates of data collection: NR Trial name: NA 

Experimental Co

POPULATION CHARACTERISTICS: Mean age: 65 Mean age: 67.3 

Age range: 50 to 81 Age range: 50 to 8

Mean age & range (years): Sex: 53% female Sex: 52% female 

Sex (% female): Race: 98% white Race: 98% white 

Race: Other population qualities: 

Experimental Co

Attrition/Drop-out (not available for 2% ( 1 patient) withdrew	 

endpoint 

measurement): 

Adherence in control group: Contamination in control group: OUTCOME ASSESSMENT: Outcome Measures: 

•	 Decision process and decision outcomes 

•	 Note that they gave the patients numerous surveys that don’t seem to have validated o

Materials given to those in experimental group don’t seem to be culturally tested or tesThere seems to be differences at baseline in the control and intervention group on somdecisional conflict (Table 2) but no data are provided. 

RESULTS: 

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KQ2 - What factors influence the use of Outcomes: 

colorectal cancer NA screening? 

KQ3 - Which strategies are effective in 

increasing the appropriate use of colorectal cancer screening and followup? 

Outcomes: 

•	 Substantially fewer patients in the experimental group chose the no screening “wait & s

physician visit: 18%versus 37% (P = 0.06). However, there was no difference between number of patients who completed planned screening tests: 14 (52%) of 27 in the contof 37 in the experimental group, P = 1.0. 

KQ4 - What are the current and Outcomes: 

projected capacities to NA deliver colorectal 
Evidence Table 2. KQ 3: Which strategies are effective in increasing the appropriate use of colorectal cancer screening and su

Authors, ref ID: Dolan, J.G., Frisina, S.76 

STUDY: Year of publication: 2002 

Dates of data collection: NR Trial name: NA 

cancer screening and surveillance at the population level? 

KQ5 - What are the effective Outcomes: 

approaches for NA monitoring the use and quality of colorectal cancer screening? 

Fair 

QUALITY RATING: 

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Evidence Table 2. KQ 3: Which strategies are effective in increasing the appropriate use of colorectal cancer screening and su

Quality Assessment-Internal Validity for Controlled Trials 

Yes No Oth

Was the study described as randomized? X Was the method of randomization adequate? X Was the treatment allocation concealed? X Were the groups similar at baseline regarding the most important prognostic indicators? X Som

ass

Was the outcome assessor blinded? X Was the care provider blinded?Was the patient blinded?Was the drop-out rate acceptable (≤ 20%)? [If between 20% and 60%, check other and explain.] Was the differential drop-out rate acceptable (≤ 15%)? 

Were co-interventions avoided or similar? 

X 

X 

X 

X NR 

Were outcome measures valid, reliable, and equally applied? Were all randomized participants analyzed in the group to which they were originally assigned? Quality Rating (Good, Fair, or Poor): Fair 

X 

X 

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Evidence Table 2. KQ 3: Which strategies are effective in increasing the appropriate use of colorectal cancer screening and su

STUDY: Authors, ref ID: Jandorf, L., Gutierrez, Y., Lopez, J., Christie, J., Itzkowitz, S.H.77 

Year of publication: 2005 Dates of data collection: January to May 2002 Trial name: Test the effectiveness of a patient navigator (PN) in increasing compliance with screening c

OBJECTIVE OR AIM: community health setting. 

Setting: Clinic; primary care practice in East Harlem, New York City 

DESIGN: Study design: Prospective clinical trial 

Duration (mean followup): 6 months Overall study size (N enrolled/N analyzed): 78 total 

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INTERVENTIONS: Sample size: Describe intervention: 

Intervention 

Sample size: 38 Intervention: Patient Navigator: provided written reminders, telephone calls, and /or scheduling assistance; FOBT card placed in chart; physicians were asked to recommend screening to patients (but did not assess whether all participants received a recommendation for endoscopic screening from their physician) 

Control 

Sample size: 40 FOBT card placed in chart to ensure clinician was blinded; physicians were asked to recommend screening to patients (but did not assess whether all participants received a recommendation for endoscopic screening from their physician) 

Patients that attended the clinic; reviewed charts of patients to find eligibility and approache

RECRUITMENT: (population-based, clinic-based, 

volunteer, other) 

Men and women; aged 50 or older 

INCLUSION CRITERIA: 

Had an FOBT within the past year; had an FS or barium enema within the past 3–5 years; h

EXCLUSION CRITERIA: the past 10 years 

Intervention Control 

POPULATION CHARACTERISTICS: Mean age: 61.1 Mean age: 61.3 

76.3% female 72.5% female 78.9% Hispanic 85% Hispanic 68.5% have public health insurance 70% have public health insurance 
Evidence Table 2. KQ 3: Which strategies are effective in increasing the appropriate use of colorectal cancer screening and su

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STUDY: Authors, ref ID: Jandorf, L., Gutierrez, Y., Lopez, J., Christie, J., Itzkowitz, S.H.77 

Year of publication: 2005 Dates of data collection: January to May 2002 Trial name: 36.8% had family history of cancer 38.5% had family history of cancer 

Mean age & range (years): Sex (% female): Race: Other population qualities: 

Total 

70% agreed to participate 

Attrition/Drop-out (not available for 

endpoint measurement): 

Adherence in control group: Contamination in control group: OUTCOME ASSESSMENT: Outcome Measures: 

•	 CRC screening; Completion of CRC screening tests was determined by a series of seq

conducted in a nonblinded fashion by the PN/RA 

•	 A second chart review took place 2–3 weeks after the initial interview and medical visit. 

as referral for FS or colonoscopy was recorded. 

•	 The third chart review was performed 3 months after the initial contact. During this time

as FS or colonoscopy completion was noted. After 6 months, the charts of all participanfourth and final time to assess FOBT, FS, and/or colonoscopy completion. 

RESULTS: KQ2 - What factors influence the use Outcomes: 

of colorectal cancer NA screening? 
Evidence Table 2. KQ 3: Which strategies are effective in increasing the appropriate use of colorectal cancer screening and su

STUDY: Authors, ref ID: Jandorf, L., Gutierrez, Y., Lopez, J., Christie, J., Itzkowitz, S.H.77 

Year of publication: 2005 Dates of data collection: January to May 2002 Trial name: 

KQ3 - Which strategies are effective in 

increasing the appropriate use of colorectal cancer screening and followup? 

KQ4 - What are the current and 

projected capacities to deliver colorectal cancer screening and surveillance at the population level? 

Outcomes: NA 

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KQ5 - What are the effective 

approaches for monitoring the use and quality of colorectal cancer screening? 

G1: 23.7% completion rate for endoscopy; 42.1% for FOBT
 G2: 5% completion rate for endoscopy (P = 0.019); 25.0% for FOBT (P = 0.086) Outcomes: NA Fair 

QUALITY RATING: 
Evidence Table 2. KQ 3: Which strategies are effective in increasing the appropriate use of colorectal cancer screening and su

Quality Assessment-Internal Validity for Controlled Trials 

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Was the study described as randomized? 

Yes X 

No 

Was the method of randomization adequate? Was the treatment allocation concealed? Were the groups similar at baseline regarding the most important prognostic indicators? X Was the outcome assessor blinded? 

X 

Was the care provider blinded? X Was the patient blinded? X Was the drop-out rate acceptable (≤ 20%)? [If between 20% and 60%, check other and explain.] X Was the differential drop-out rate acceptable (≤ 15%)? X 

Were co-interventions avoided or similar? X Were outcome measures valid, reliable, and equally applied? X Were all randomized participants analyzed in the group to which they were originally assigned? X Quality Rating (Good, Fair, or Poor): Fair Applicability Assessment 

Mean age 61.2, primarily Hispanic women 

Population 

Patient Navigator: provided written reminders, telephone calls, and /or scheduling assistance 

Intervention 

Control group that received an FOBT card and recommendation from physician for screening 

Comparison 

CRC screening rates 

Outcomes 

3 and 6 months 

Timing of follow-up 

Clinic 

Setting 
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Evidence Table 2. KQ 3: Which strategies are effective in increasing the appropriate use of colorectal cancer screening and suSTUDY:	 Authors, ref ID: Ling BS, Schoen RE, Trauth JM, Wahed AS, Eury T, Simak DM, Solano 

Year of publication: 2009 Dates of data collection: June 1, 2002, through April 30, 2004 Trial name: NA 

OBJECTIVE OR AIM: In a controlled study of primary care patients eligible for colorectal cancer screening, auth

PPIP-based physician office and patient management interventions for their effect on comscreening.
 

DESIGN: Setting: 10 Primary care practices participating in the Physician Research in Office Netwo

Study design: Randomized controlled trial. 2x2 factorial design.
 

Duration (mean followup): 1 year Overall study size (N enrolled/N analyzed): 599 patients 

Methods: Practices were paired according to the number of physicians, specialty, location, and clien

one member of each pair to enhanced office and patient management and the second to patients management. Within each physician group practice, eligible patients were randoreceive a personalize (tailored ) or nonpersonalized letter that recommended endoscopic Flips of a coin witnessed by a person not involved in the research was used to allocate prgenerated random numbers to allocate individuals. Patients were recruited via a mailed packet (see Recruitment). Following recruitment and received letters recommending endoscopic CRC screening and asking recipients to telephThe non tailored letter lacked a personalized salutation or patient specific content. The tapersonalized salutation, named the personal physician, commented on the patients age, fCRC testing. 

INTERVENTIONS: Enhanced Office and Patient Management Nonenhanced Office and Patie

Sample size: Practices (with and without tailored letters to (with and without tailored 

patients) Intervention: In the nonenhanced 

Describe intervention: Intervention: The enhanced office and patient management intervention, authors 

management intervention used research staff to help office staff members about coloreoffice staff (1) adapt office-based protocols for guidelines and common barriers aendoscopic screening referral, (2) track patient to colorectal cancer screening. Woutcomes, and (3) resolve patient-specific barriers to managers, authors also helped ofscreening. They also worked with the office staff to guide patient referrals for endoscodevelop protocols for CRC screening and implement gastrointestinal tract. The nonenhthem within their practice. This was combined with: represented a current standard of 

use published tools (e.g., PPIP10

Tailored letter mailed to patients (n=152) initiate and sustain office proceduNo tailored letter sent (n=190)	 preventive clinical services. This w

Tailored letter mailed to patients (No tailored letter sent (control gro

RECRUITMENT: Clinic-based (primary care physician-based practices). 10 practices from among unknow(population-based, clinic-based, practices were identified and recruited. Patients within these practices were recruited via: 
Evidence Table 2. KQ 3: Which strategies are effective in increasing the appropriate use of colorectal cancer screening and su

STUDY:	 Authors, ref ID: Ling BS, Schoen RE, Trauth JM, Wahed AS, Eury T, Simak DM, Solano 

Year of publication: 2009 Dates of data collection: June 1, 2002, through April 30, 2004 Trial name: NA 

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volunteer, other) identified age-=eligible patients who had an office visit in the preceding fiscal year. Patien

with an invitation letter requesting participation in the project. The packet also included a questions about exclusion criteria. 

INCLUSION CRITERIA:	 Patients aged 50 to 79 years, no personal history of colorectal cancer or polyp and no rec

tract procedures (FS or BE in 5 years or colonoscopy in 10 years) 

EXCLUSION CRITERIA: Patients with a personal history of colorectal cancer or polyp, recent lower gastrointestinaPOPULATION CHARACTERISTICS: Enhanced Office and Patient Management Nonenhanced Office and 

Sex: 56.7% women Sex: 52.9% women 

Mean age & range (years): Age: 36.3% age 50-54, 24.6% age 55-59, 14.3% age Age: 31.1% age 50-54, 22.2% ag

Sex (% female): 60-64, 10.8% age 65-69, 7.9% age 70-74, 6.1% age 13.6% age 65-69, 12.5% age 70-7

Race: 75+ Race: 84.4% White, 15.6% Other 

Other population qualities: Race: 90% White, 10% Other Attrition/Drop-out (not available for Tailored/enhanced Nontailored/enhanced Tailored/nonenhanced N

endpoint measurement): 92.1% completed 86.8% completed follow-up 96.2% completed follow-up 96.Adherence in control group: follow-up Contamination in control group: OUTCOME ASSESSMENT: Outcome Measures: 

•	 The primary end point was medical-record-verified flexible sigmoidoscopy o

•	 To ascertain procedures missed by medical record reviews, authors telepho

enhanced and nonenhanced management intervention to ask about compleThe enhanced office intervention included periodic telephone contacts. Authpatients in the non enhanced management intervention after the anniversary medical record reviews failed to document occurrence of the end point. 

•	 Statistical end-point analysis (according to randomization intent) used gener

to account for correlated outcomes according to physician group. 

•	 Because authors realized that the outcome from 2 individuals belonging to t

physician practices will be correlated, statistical analysis of the clinical trial eaccording to randomization intent) used generalized estimating equation (GEassociation of interventions with the outcome. This approach consists of 2 msimultaneously. The main model specifies the logistic regression of the outcvariables and the other model accounts for the correlations between patients belonging to the same physician group practice (within practice) and to the s(between practice). 

•	 Authors used alternate logistic regression models to specify within- and betw

in terms of pair-wise odds ratios. 

RESULTS: KQ2 - What factors influence the use of NA 

colorectal cancer screening?
 KQ3 - Which strategies are effective in Outcomes: 
Evidence Table 2. KQ 3: Which strategies are effective in increasing the appropriate use of colorectal cancer screening and su

STUDY:	 Authors, ref ID: Ling BS, Schoen RE, Trauth JM, Wahed AS, Eury T, Simak DM, Solano 

Year of publication: 2009 Dates of data collection: June 1, 2002, through April 30, 2004 Trial name: NA 

increasing the appropriate use of • During a one year period, endoscopy occurred in 48.2%. This included: 53

colorectal cancer screening and with tailored letter and enhanced management, 54.2% in the group with nonfollowup? enhanced management; 43.6% in the group with tailored letter and nonenha

37.9% in the group with nontailored letter and nonenhanced management. 

• Enhanced management increased the odds of completing a colonoscopy or 

1.11-2.41). However, the tailored letter increased the odds of completion by 

KQ4 - What are the current and NA projected capacities to deliver colorectal cancer screening and surveillance at the population level? KQ5 - What are the effective approaches NA for monitoring the use and quality of colorectal cancer screening? QUALITY RATING: Fair 

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Evidence Table 2. KQ 3: Which strategies are effective in increasing the appropriate use of colorectal cancer screening and su

Quality Assessment-Internal Validity for Controlled Trials Was the study described as randomized? 

Yes 

X 

No Other (CD, NR, NA) 

Was the method of randomization adequate? X Was the treatment allocation concealed? Were the groups similar at baseline regarding the most important prognostic indicators? Was the outcome assessor blinded? 

X 

X 

Was the care provider blinded? Was the patient blinded? Was the drop-out rate acceptable (≤ 20%)? [If between 20% and 60%, check other and explain.] Was the differential drop-out rate acceptable (≤ 15%)? 

Were co-interventions avoided or similar? 

X 

X 

X 

X 

X 

Were outcome measures valid, reliable, and equally applied? x Phone contact with enhanced group was greater

measurement bias 

Were all randomized participants analyzed in the group to X which they were originally assigned? Quality Rating (Good, Fair, or Poor): Fair Applicability Assessment: 

Population Patients age 50-79 Intervention Enhanced office and patient-based management training Comparison Compared those with enhanced and non-enhanced management training Outcomes Flexible sigmoidoscopy or colonoscopy Timing of follow-up 1 year Setting Primary care practices 

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Evidence Table 2. KQ 3: Which strategies are effective in increasing the appropriate use of colorectal cancer screening and su

Authors, ref ID: Myers, RE, Sifri, R, Hyslop, T, Rosenthal, M, Vernon, SW, Cocroft, J, Wo

STUDY: Wender, R 79 

Year of publication: 2007 Dates of data collection: 2002-2004 Trial name: NR To determine whether targeted and tailored interventions can increase screening use. 

OBJECTIVE OR AIM: 

Setting: Jefferson Family Medicine Associates (JFMA), a large urban practice located at T

DESIGN: University in Philadelphia (1 central practice site) 

Study design: RCT Duration (mean followup): 24 months Overall study size (N enrolled/N analyzed): 1546/1546 

SI TI TIP 

INTERVENTIONS: 387 386 386 

Sample size: Targeted intervention by mail (i.e., personalized screening invitation SI intervention plus Targeted intervention (SI and TI combined) Targeted intervention, 

letter, informational booklet, FOBT with tailored “message tailored message pages, 

fit, and reminder letter) pages.” and a telephone 

reminder. 

Describe intervention: 

Clinic-based; practice billing database was used to identify potential study participants. In 

RECRUITMENT: 2002, JFMA sent a letter to potential participants introducing the research study. The lette

the purpose of the study, provided details regarding participation, and explained opt-out pr

(population-based, clinic-based, 

volunteer, other) 

Adult male and female patients of JFMA, between 50-74 years old, no prior diagnosis with 

INCLUSION CRITERIA:	 inflammatory bowel disease, had had at least one visit to JFMA within the previous 2 years

information (i.e., address and telephone number) available, and had not undergone recent latter criterion related to having an SBT within the previous year, FS within the previous 5 ywithin the previous 5 years, or a colonoscopy within the previous 10 years. See above 

EXCLUSION CRITERIA: 

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Evidence Table 2. KQ 3: Which strategies are effective in increasing the appropriate use of colorectal cancer screening and su

STUDY: 

Authors, ref ID: Myers, RE, Sifri, R, Hyslop, T, Rosenthal, M, Vernon, SW, Cocroft, J, WoWender, R 79 

Year of publication: 2007 Dates of data collection: 2002-2004 Trial name: NR 

POPULATION CHARACTERISTICS: Overall Mean age & range (years): 

NR 67% 58% African American 

Sex (% female): Race: 

5% 51% 41% 

Other population qualities: Family history of CRC > high school education Prior cancer screening test 

SI TI TIP 

19% 19% 20% 

Attrition/Drop-out (not available for 

endpoint measurement): 

Adherence in intervention group: Contamination in control group: OUTCOME ASSESSMENT: Outcome Measures: 

Screening use 

RESULTS: KQ2 - What factors influence the use of 

colorectal cancer screening? 

NA 

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Evidence Table 2. KQ 3: Which strategies are effective in increasing the appropriate use of colorectal cancer screening and su

STUDY: 

Authors, ref ID: Myers, RE, Sifri, R, Hyslop, T, Rosenthal, M, Vernon, SW, Cocroft, J, WoWender, R 79 

Year of publication: 2007 Dates of data collection: 2002-2004 Trial name: NR 

KQ3 - Which strategies are effective in 

increasing the appropriate use of colorectal cancer screening and followup? 

Outcomes: 

• Univariate analyses showed screening rates in study groups were 33% in the control g

group, 44% in the TI group, and 48% in the TIP group. Screening was found to be signintervention groups compared with the control group (OR 1.7 [95% CI 1.3–2.5], OR 1.6 OR 1.9 [95% CI, 1.4–2.6], respectively), but did not vary significantly across interventio

KQ4 - What are the current and 

projected capacities to deliver colorectal cancer screening and surveillance at the population level? 

KQ5 - What are the effective 

approaches for monitoring the use and quality of colorectal cancer screening? 

Outcomes: NA Outcomes: NA Fair 

QUALITY RATING: 

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Evidence Table 2. KQ 3: Which strategies are effective in increasing the appropriate use of colorectal cancer screening and su

Quality Assessment-Internal Validity for Controlled Trials Was the study described as randomized? Was the method of randomization adequate? Was the treatment allocation concealed? 

Yes X X 

No 

X 

Were the groups similar at baseline regarding the most important prognostic indicators? Was the outcome assessor blinded? 

X 

Was the care provider blinded?Was the patient blinded?Was the drop-out rate acceptable (≤ 20%)? [If between 20% and 60%, check other and explain.] Was the differential drop-out rate acceptable (≤ 15%)? 

Were co-interventions avoided or similar? 

X 

X 

X X X 

Were outcome measures valid, reliable, and equally applied? Were all randomized participants analyzed in the group to which they were originally assigned? Quality Rating (Good, Fair, or Poor): Fair 

X 

X 

Applicability Assessment Population Intervention 

Patients (50-74) of a large urban primary care practice Standard and tailored interventions to increase CRC screening Usual care 

Comparison Outcomes 

CRC screening 24 months after intervention 

Timing of follow-up Setting 

Primary care practice center 

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Evidence Table 2. KQ 3: Which strategies are effective in increasing the appropriate use of colorectal cancer screening and su

Authors, ref ID: Pignone, M., Harris, R., Kisinger, L.80 

STUDY: Year of publication: 2000 

Dates of data collection: May to November 1998 Trial name: NA To test whether a decision aid consisting of an educational video, targeted brochure, and 

OBJECTIVE OR AIM: performance of colon cancer screening in primary care practices. 

Setting: Community primary care practices 

DESIGN: Study design: Randomized controlled trial 

Duration (mean followup): 3-month chart review Overall study size (N enrolled/N analyzed): 249 

INTERVENTIONS: Sample size: Describe intervention: 

Intervention 

Sample size: 125 Intervention: Questionnaire about intentions for CRC screening, watched video about CRC screening options, received brochure about CRC screening, then another questionnaire about CRC screening intentions 

Contro

Sample size: 124 Intervention: Questionnaire about inscreening, watched video about traquestionnaire about CRC screening 

Clinic-based; Patients were contacted by telephone before their scheduled visits and aske

RECRUITMENT: of preventive care. (population-based, clinic-based, 

volunteer, other) 

Adults 50 to 75 years of age who were scheduled to be seen for a new or ongoing health 

INCLUSION CRITERIA: participating providers from the three practices 

Reported a personal or family history of colon cancer, had home fecal occult blood testing 

EXCLUSION CRITERIA: flexible sigmoidoscopy, colonoscopy, or barium enema in the past 5 years, were judged b

be too ill to participate, or appointments were only for laboratory blood work. 

Intervention Control 

POPULATION CHARACTERISTICS: Mean age: 63.1 Mean age: 62.7 

Sex: 59% female Sex: 61% female Race: 84% white Race: 90% white 

Mean age & range (years): Sex (% female): Race: Other population qualities: 

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Evidence Table 2. KQ 3: Which strategies are effective in increasing the appropriate use of colorectal cancer screening and su

Authors, ref ID: Pignone, M., Harris, R., Kisinger, L.80 

STUDY: Year of publication: 2000 

Dates of data collection: May to November 1998 Trial name: NA 

Attrition/Drop-out (not available for 

endpoint measurement): 

All None 

Adherence in control group: Contamination in control group: OUTCOME ASSESSMENT: Outcome Measures: 

Intervention group participants were less likely than controls to have graduated from high were more likely to have Medicare as their main form of insurance (56% vs. 45%). 

RESULTS: KQ2 - What factors influence the use of Outcomes: 

colorectal cancer N screening? 

KQ3 - Which strategies are effective in 

increasing the appropriate use of colorectal cancer screening and followup? 

KQ4 - What are the current and 

projected capacities to deliver colorectal cancer screening and surveillance at the population level? 

Outcomes: 

•	 At baseline, the mean score for intent to ask for screening (measured on a 4-point Lik

groups. 

•	 After the participants watched the video, the mean 6 SD score for intent to ask for scr

higher in the intervention group (3.1 6 1.0) than the control group (2.5 6 1.1) (P , 0.00In the intervention group, 50.0% of participants moved from low (1 or 2) to high (3 or 4after watching the video compared with 26.5% of controls. 

•	 When asked after their visits whether they had had any conversation about colon can

intervention group participants and 43.4% of controls reported some conversation (difpoints [95% CI, 12.7 to 37.6 percentage points]).
 

•	 For the main outcome of any test completed, the absolute difference between the inte

control (22.6%) groups was 14.2 percentage points (CI, 3.0 to 25.4 percentage points

Outcomes: NA 

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Evidence Table 2. KQ 3: Which strategies are effective in increasing the appropriate use of colorectal cancer screening and su

Authors, ref ID: Pignone, M., Harris, R., Kisinger, L.80 

STUDY: Year of publication: 2000 

Dates of data collection: May to November 1998 Trial name: NA 

KQ5 - What are the effective approaches Outcomes: 

for monitoring the use NA and quality of colorectal cancer screening? 

Fair 

QUALITY RATING: 

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Evidence Table 2. KQ 3: Which strategies are effective in increasing the appropriate use of colorectal cancer screening and su

Quality Assessment-Internal Validity for Controlled Trials 

Yes No 

Was the study described as randomized? X Was the method of randomization adequate? X Was the treatment allocation concealed? 

X 

Were the groups similar at baseline regarding the most important prognostic indicators? X 

Was the outcome assessor blinded? X 

Was the care provider blinded? X Was the patient blinded? X Was the drop-out rate acceptable (≤ 20%)? [If between 20% and 60%, check other and explain.] X Was the differential drop-out rate acceptable (≤ 15%)? X 

Were co-interventions avoided or similar? X Were outcome measures valid, reliable, and equally applied? X 

Were all randomized participants analyzed in the group to which they were originally assigned? X Quality Rating (Good, Fair, or Poor): Fair Applicability Assessment 

North Carolina adults age 50-75 

Population 

Questionnaire about intentions for CRC screening, watched video about CRC screening options, received b

Intervention screening, then another questionnaire about CRC screening intentions 

Compared to patients who received a video about traffic safety 

Comparison 

CRC screening rates 

Outcomes 

3 month chart review 

Timing of follow-up 

Primary care clinics 

Setting 

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Evidence Table 2. KQ 3: Which strategies are effective in increasing the appropriate use of colorectal cancer screening and su

STUDY:	 Authors, ref ID: Potter MB, Phengrasamy L, Hudes ES, McPhee SJ, Walsh JME81 

Year of publication: 2009 Dates of data collection: September 2006-March 31, 2007 Trial name: NA 

OBJECTIVE OR AIM: Authors wanted to determine whether providing home fecal occult blood test (FOBT) kits t

influenza inoculation (flu shot) clinics can contribute to higher colorectal cancer screening 

DESIGN: Setting: Family Health Center, a residency-based clinic at San Francisco General Hospita

Study design: Time-randomized trial Duration (mean followup): Overall study size (N enrolled/N analyzed): 514 

INTERVENTIONS: Control Intervention 

Sample size: Sample size: 8 flu shot sessions, Sample size: 9 flu shot session, 264 

n= 247 flu shots given 

Describe intervention: Intervention: Flu shot given Intervention: Flu shot and FOBT kit 

given 

RECRUITMENT: Clinic-based; patients aged 50 to 79 years were mailed multilingual flu shot campaign ann(population-based, clinic-based, in English, Chinese, Russian, Spanish, and Vietnamese volunteer, other) INCLUSION CRITERIA: Age 50-79 years, had not had a FOBT since the end of the prior influenza season, a colon

years, any previously unevaluated abnormal FOBT results, a history of recent unevaluatewith FS in the last 5 years alone were eligible. 

EXCLUSION CRITERIA: NR POPULATION CHARACTERISTICS: Control	 Intervention 

Mean age: 65.6 Mean age: 63.7 

Mean age & range (years): Sex: 65.9% female Sex: 61.2% female 

Sex (% female): Ethnicity: 6.1% African American, Ethnicity: 5.6% African American, Race: 56.1% Asian/Pacific Islander, 25.2% 48.1% Asian/Pacific Islander, 35.8% Other population qualities: Latino, 9.8% Non-Latino White, 2.8% Latino, 7.8% Non-Latino White, 2.6% 

Other/Unknown Other/Unknown 

Overall Group 2 

Attrition/Drop-out (not available for 264 flu shots given endpoint measurement): 153 eligible for FOBT Adherence in control group: 149 offered FOBT and 4 missed Contamination in control group: 143 given FOBT and 6 refused OUTCOME ASSESSMENT: Outcome Measures: 

•	 The primary study outcome was change in CRCS up-to-date status from be

defined as not having a FOBT in the last year, a flexible sigmoidoscopy or denema in the past 5 years, a colonoscopy in the past 10 years, or having anabnormal FOBT results or recent unevaluated rectal bleeding, to having com

•	 Authors compared baseline characteristics of the intervention and control gr

test for continuous variables and the Pearson χ2 test for categorical variable

•	 To compare the changes in CRCS status between the 2 study arms, a −1, 0

the preintervention to postintervention change for each patient. In this scorin

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Evidence Table 2. KQ 3: Which strategies are effective in increasing the appropriate use of colorectal cancer screening and su

STUDY:	 Authors, ref ID: Potter MB, Phengrasamy L, Hudes ES, McPhee SJ, Walsh JME81 

Year of publication: 2009 Dates of data collection: September 2006-March 31, 2007 Trial name: NA 

being due for screening at preintervention and up-to-date at postintervention

date at preintervention and due for screening at postintervention; and 0 indicpostintervention change in CRCS status. 

•	 A 2-sample Wilcoxon test was used to compare these change scores for the 

arm, the McNemar test was used to compare preintervention to postintervenchange in CRCS status. 

•	 Using available preselected predictor variables that have been associated w

completion, authors next explored predictors of CRCS with multivariate logis

RESULTS: KQ2 - What factors influence the use of NA
 

colorectal cancer screening?
 KQ3 - Which strategies are effective in G1: 83 (68.0%) became up-to-date with any CRC screening at follow-up (29.8 percentage increasing the appropriate use of baseline; 95% CI, 23.7- 36.0)
 colorectal cancer screening and G2: 24 (20.7%) became up-to-date with any CRC test (4.4 percentage point change; 95% followup?
 

P < 0.001 

KQ4 - What are the current and NA projected capacities to deliver colorectal cancer screening and surveillance at the population level? KQ5 - What are the effective approaches NA for monitoring the use and quality of colorectal cancer screening? QUALITY RATING: Good 

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Evidence Table 2. KQ 3: Which strategies are effective in increasing the appropriate use of colorectal cancer screening and su

Quality Assessment-Internal Validity for Controlled Trials Was the study described as randomized? Was the method of randomization adequate? Was the treatment allocation concealed? 

Yes 

X 

X 

No 

X 

Other (CD, NR, NA) 

Not well described 

Were the groups similar at baseline regarding the most important prognostic indicators? Was the outcome assessor blinded? 

X Except for age, p=.004 

Not stated 

Was the care provider blinded? Was the patient blinded? Was the drop-out rate acceptable (≤ 20%)? [If between 20% and 60%, check other and explain.] Was the differential drop-out rate acceptable (≤ 15%)? 

Were co-interventions avoided or similar? 

x 

X 

x 

x 

The clinic staff was not told in advance on what d

the intervention. However, contamination possibconducting flu shots on all days 

NA 

Were outcome measures valid, reliable, and equally applied? Were all randomized participants analyzed in the group to which they were originally assigned? Quality Rating (Good, Fair, or Poor): Good 

X 

X 

Applicability Assessment: Population Patients age 50-79 in a San Francisco clinic Intervention FOBT kits handed out during flu shots Comparison Compared FOBT screening rates of patients who had flu shot with no FOBT kit and those who received an FOBOutcomes FOBT screening Timing of follow-up FOBT returned within 7 months Setting Clinic in San Francisco 

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STUDY:	 Authors, ref ID: Roetzheim RG, Christman LK, Jacobsen PB, Cantor AB, Schroeder J, A

Chirikos TN, Krischer JP 82) AND {#3521 

Year of publication: 2004, 2005 Dates of data collection: Trial name: 

OBJECTIVE OR AIM: Authors developed a low-cost office systems intervention, Cancer Screening Office Syste

primary care clinics serving disadvantaged populations. Authors tested the efficacy of the 

attending community health centers, a representative setting of care for the target populat

DESIGN: Setting: Community health centers 

Study design: Randomized controlled trial Duration (mean followup): Follow-up at 12 and 24 months Overall study size (N enrolled/N analyzed): 8 clinics—each time period, a different set owere selected for data collection—1196 at baseline; 1237 at 12 months; 1296 at 24 month

INTERVENTIONS: Intervention Group ContrSample size: Sample size: 600 Sample size: 596 

Intervention: Key components of the intervention Intervention: Control 

Describe intervention: included a cancer-screening checklist completed by patients 

and indicating whether patients were due for screening, and a series of red, yellow, and green stickers that indicated whether recommended screening tests had been ordered and completed. 

RECRUITMENT: Clinic-based; To target an underserved population, clinics were recruited from among 16 c

(population-based, clinic-based, county-funded health insurance plan in Hillsborough County, Fla. volunteer, other) INCLUSION CRITERIA: • Clinics were eligible for the randomized trial if (1) they provided primary med

(2) a majority of the physician and nonphysician providers agreed to participexpected to continue operating in the same fashion for the following 24 mon

•	 Patient’s records were eligible to be abstracted if both the following criteria w

was 50 to 75 years of age, and (2) the patient was established in the clinic (dleast 1 visit 12 months or more before the sampled visit). 

EXCLUSION CRITERIA:	 Patients with a personal history of colon cancer and those who had received a colonoscop

barium enema in the previous 10 years were excluded from the analysis of FOBT. 

POPULATION CHARACTERISTICS: Intervention Group	 Control G

Age: 38.7% 50-56, 33.1% 57-63, 28.3% 64-75 Age: 35.6% 50-56, 32.9% 57-63

Mean age & range (years): Sex: 78% female Sex: 78% female 

Sex (% female): Race: 34% African American, 45.3% White, 20.7% Race: 24.2% African American, Race: Hispanic Hispanic Other population qualities: 

Intervention Group Control G

Attrition/Drop-out (not available for NA NA endpoint measurement): Adherence in control group: Contamination in control group: 

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STUDY:	 Authors, ref ID: Roetzheim RG, Christman LK, Jacobsen PB, Cantor AB, Schroeder J, A

Chirikos TN, Krischer JP 82) AND {#3521 

Year of publication: 2004, 2005 Dates of data collection: Trial name: 

OUTCOME ASSESSMENT: Outcome Measures: 

•	 Authors defined being up-to-date as having completed FOBT within either th

audited visit or within the 3 months after the audited visit. 

•	 Chart abstracters used a standardized method and instrument to abstract ch

trained by the project manager. Relevant clinical data were abstracted from including progress notes, laboratory reports, radiology reports, consultation records. 

•	 Interrater reliability was calculated (0.91) 

RESULTS: KQ2 - What factors influence the use of NA colorectal cancer screening? KQ3 - Which strategies are effective in increasing the appropriate use of colorectal cancer screening and followup? 

Outcomes: At the 12 month follow-up 

•	 FOBT screening rates in intervention group was 40.1% vs. 11.9% in control • Multivariate analysis results: FOBT – Odds ratio=2.56, 95% CI 1.65-4.01, p<

At 24 months, the intervention had no significant effect on FOBT screening 

•	 OR =1.17 (95% CI, 0.92-1.48) 

•	 When results were repeated comparing patients having a Cancer SOS scree

who did not, presence of a checklist was associated with increased odds of 3.28; 95% CI, 2.05-5.23; P <.0001). 

•	 Compliance with the Cancer SOS intervention decreased during the course 

334 of 615 (54.3%) showing evidence of the checklist at 24 months, compar

KQ4 - What are the current and NA projected capacities to deliver colorectal cancer screening and surveillance at the population level? KQ5 - What are the effective approaches NA for monitoring the use and quality of colorectal cancer screening? QUALITY RATING: Fair 

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Quality Assessment-Internal Validity for Controlled Trials Was the study described as randomized? 

Yes 

X 

No Other (CD, NR, NA) 

Was the method of randomization adequate? Not described Was the treatment allocation concealed? NR Were the groups similar at baseline regarding the most X Except for race: Intervention-34% African Americimportant prognostic indicators? White, 20.7% Hispanic; Control- 24.2% African A

51.5% White, 24.3% Hispanic 

Was the outcome assessor blinded? X Was the care provider blinded? X Was the patient blinded? X Was the drop-out rate acceptable (≤ 20%)? [If between 20% NA and 60%, check other and explain.] Was the differential drop-out rate acceptable (≤ 15%)? NA 

Were co-interventions avoided or similar? X Were outcome measures valid, reliable, and equally applied? Were all randomized participants analyzed in the group to which they were originally assigned? Quality Rating (Good, Fair, or Poor): Fair 

X 

X 

Applicability Assessment: Population Patients 50 to 75 years of age who went to a community health clinic in Hillsborough County, FL. 

Intervention Cancer-screening checklist completed by patients and indicating whether patients were due for screening, 

yellow, and green stickers that indicated whether recommended screening tests had been ordered and com

Comparison Compared patients who received intervention to those who did not. Outcomes FOBT screening Timing of follow-up 12 and 24 months Setting Community health centers 

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Authors, ref ID: Ruffin, MT, Fetters, MD, & Jimbo, M 83 

STUDY: Year of publication: 2007 

Dates of data collection: 2002-2003 Trial name: Compare Colorectal Web and an existing stand-alone Web site in a RCT 

OBJECTIVE OR AIM: DESIGN: 

Setting: 5 urban, suburban, rural communities in MI Study design: RCT Duration (mean followup): 24 weeks Overall study size (N enrolled/N analyzed): 174/174 

Intervention Control 

INTERVENTIONS: • 87 • 87 

• At study sites that were community locations Sample size: (hotels, meeting rooms in malls, other public 

meeting areas) participants were provided a laptop and they viewed either the Colorectal web or alternative website 

Describe intervention: 

• Population based 

RECRUITMENT: • 5 communities selected based on 1) CRC burden and 2) presence of minority populati

• List of 3000 residential telephone numbers likely to meet the age and geographical elig

(population-based, clinic-based, purchased by a marketing company (1000 each urban, suburban, rural) 

volunteer, other) • Up to 5 calls per number to recruit 

• Between ages of 50-70 

INCLUSION CRITERIA: • Resident in one of the urban, suburban, or rural communities selected in MI 

• Not previously screened for CRC • Comfortable using a computer to find information on the Internet • Self-reported health status better than poor 

‘Screened for CRC’, Age, ability to use computer (no explanation of how that’s assessed), 

EXCLUSION CRITERIA: 

Intervention Control 

POPULATION CHARACTERISTICS: 56.9 57.4 

52 57 

Mean age & range (years): Sex (% female): Race: 

54 46 

52 48 

Caucasian African-American Other population qualities: 

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Authors, ref ID: Ruffin, MT, Fetters, MD, & Jimbo, M 83 

STUDY: Year of publication: 2007 

Dates of data collection: 2002-2003 Trial name: 

Attrition/Drop-out (not available for 

endpoint measurement): 

Intervention 

0 

Control 

0 

Adherence in control group: Contamination in control group: OUTCOME ASSESSMENT: Outcome Measures: 

Follow up phone calls at 2, 8, 24 weeks to ascertain whether participant had been screene

RESULTS: KQ2 - What factors influence the use of Outcomes: 

colorectal cancer screening? 

KQ3 - Which strategies are effective in 

increasing the appropriate use of colorectal cancer screening and followup? 

Outcomes: 

•	 Main result: At 24 weeks, 89 persons had been screened. In intervention group, 56% c

compared to 33% in control group (23 percentage point difference; AOR, 3.23; 95% C

•	 In a logistic regression model, with exposure to Colorectal Web, age, gender, ethnicity

screening, and interaction term between preference and exposure to Colorectal Web, outcome, exposure to the intervention was associated with the outcome (OR = 3.23, C

KQ4 - What are the current and Outcomes: 

projected capacities to deliver colorectal cancer screening and surveillance at the population level? 

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Authors, ref ID: Ruffin, MT, Fetters, MD, & Jimbo, M 83 

STUDY: Year of publication: 2007 

Dates of data collection: 2002-2003 Trial name: 

KQ5 - What are the effective Outcomes: 

approaches for monitoring the use and quality of colorectal cancer screening? 

Good 

QUALITY RATING: 

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Quality Assessment-Internal Validity for Controlled Trials 

Yes No 

Was the study described as randomized? X Was the method of randomization adequate? X Was the treatment allocation concealed? X Were the groups similar at baseline regarding the most important prognostic indicators? X Was the outcome assessor blinded? X Was the care provider blinded? X Was the patient blinded? X Was the drop-out rate acceptable (≤ 20%)? [If between 20% and 60%, check other and explain.] X
 Was the differential drop-out rate acceptable (≤ 15%)? X Were co-interventions avoided or similar? X Were outcome measures valid, reliable, and equally applied? X Were all randomized participants analyzed in the group to which they were originally assigned? X Quality Rating (Good, Fair, or Poor): Good Applicability Assessment 

Urban, suburban, rural residents of one state 

Population 

Supervised viewing of a website, results may not translate to spontaneous viewing at home 

Intervention 

Viewing of a control website (standard site on CRC) 

Comparison 

Self-reported CRC screening 

Outcomes 

24 weeks, appropriate 

Timing of follow-up 

Viewing websites under a research setting, in public spaces, likely is not the same as viewing websites at hom

Setting 

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STUDY:	 Authors, ref ID: Sequist TD, Zaslavsky AM, Marshall R, Fletcher RH, Ayanian JZ 84 

Year of publication: 2009 Dates of data collection: April 2006 to June 2007 Trial name: NA 

OBJECTIVE OR AIM: Authors conducted a randomized controlled trial to compare the individual and joint impact of pe

patients and electronic reminders to primary care physicians to promote colorectal cancer scree

group practice. 

DESIGN: Setting: Harvard Vanguard Medical Associates (HVMA), a multispecialty group practice compo

health care centers in eastern Massachusetts Study design: Randomized controlled trial Duration (mean followup): Screening within 15-month study period Overall study size (N enrolled/N analyzed): 21,860 patients and 110 primary care physicians 

INTERVENTIONS: Patient Mailing Patient Control Physician Remind

Sample size: Sample size: 10,930 Patients Group Sample size: 55 

Intervention: Patients overdue for colorectal Sample size: 10,930 Physicians 

Describe intervention: cancer screening received a mailing with the Patients Intervention: Throug

following 4 components: (1) a cover letter from Intervention: control the 15-month interven

the HVMA chief medical officer identifying the period, physicians 

patient as overdue for screening and indicating received electronic the dates of their most recent screening reminders during officexaminations, (2) an educational pamphlet visits with their patiendetailing screening options, (3) an FOBT kit overdue for colorectawith 3 Coloscreen stool cards from Helena cancer screening. Laboratories Corporation, Beaumont, Texas, instructions, and a stamped return envelope, and (4) a dedicated telephone number to schedule flexible sigmoidoscopy or colonoscopy. 

RECRUITMENT: Clinic-based 

(population-based, clinic-based, volunteer, other) INCLUSION CRITERIA: Patients aged 50 to 80 years who had a visit with 1 of the 110 primary care physicians at 11 cen

months 

EXCLUSION CRITERIA: Patients who had been screened for colorectal cancer in accordance with the HVMA clinical gui

either flexible sigmoidoscopy within 5 years along with FOBT in the prior year or colonoscopy w

POPULATION CHARACTERISTICS: Mean age & range (years): Sex (% female): Race: Other population qualities: 

Patient Mailing 

Intervention 

Mean age: 60.5 Sex: 56.8% female Race: 58% White, 8% Black, 2% Hispanic, 2% Asian, 3% Other, 27% Unknown 

 Patient Mailing 

Patient Control 

Mean age: 60.4 Sex: 57% female Race: 57% White, 8% Black, 2%Hispanic, 3% Asian, 3% Other, 27% Unknown 

Patient Control

Physician Reminder 

Mean age: 60.3 Sex: 54% female Race: 57% White, 9% Black, 2% Hispanic, 2% Asian, 3% Other, 28% Unknown 

 Physician Reminder

S2O

 

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STUDY:	 Authors, ref ID: Sequist TD, Zaslavsky AM, Marshall R, Fletcher RH, Ayanian JZ 84 

Year of publication: 2009 Dates of data collection: April 2006 to June 2007 Trial name: NA 

Attrition/Drop-out (not available for Intervention 0% drop-out 0% drop-out 0

endpoint measurement): 0% drop-out Adherence in control group:
 Contamination in control group: OUTCOME ASSESSMENT: Outcome Measures:
 

•	 All data were collected from the electronic record, and study outcomes were asses

the start of the intervention for all randomized patients. 

•	 The primary study outcome was completion of 1 of the following 3 options during t

FOBT, flexible sigmoidoscopy, or colonoscopy. 

•	 Because the detection and removal of precancerous adenomas is a major objectiv

screening,29 the secondary study outcome was detection of adenomas based on 

RESULTS: 

KQ2 - What factors influence the NA use of colorectal cancer screening? KQ3 - Which strategies are Outcomes: effective in increasing the • Among this group of patients who were overdue for screening with usual care, patappropriate use of colorectal mailing were significantly more likely to complete colorectal cancer screening than cancer screening and followup? vs. 38.1%; P_.001). 

•	 The mailing primarily increased the performance of FOBT among the intervention 

control group (25.4% vs. 20.4%; P<.001). 

•	 Patients whose physicians received electronic reminders during the study period w

patients whose physicians did not receive reminders to complete colorectal screenP=.47), but among patients with 3 or more primary care visits, reminders tended to (59.5% vs. 52.7%; P=.07) 

•	 The interaction between the patient intervention and the physician intervention wa

statistically significant (−0.6%; 95% CI, −1.2% to 0.1%) (P=.08), indicating that the 

combined patient and physician reminders was 0.6% less than the sum of their effindividually. 

KQ4 - What are the current and NA projected capacities to deliver colorectal cancer screening and surveillance at the population level? KQ5 - What are the effective NA approaches for monitoring the use and quality of colorectal cancer screening? QUALITY RATING: Good 

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Evidence Table 2. KQ 3: Which strategies are effective in increasing the appropriate use of colorectal cancer screening and su

Quality Assessment-Internal Validity for Controlled Trials 

Yes No Other (CD, NR, NA) 

Was the study described as randomized? X Was the method of randomization adequate? X Within each physician panel, authors paired patients overd

values of this propensity and randomly assigned 1 patient iintervention mailing, thus closely balancing treatment groupto their baseline screening propensity. The physician intervthe physician level. Within each health care center, authors similar colorectal cancer screening rates and numbers of pscreening and then randomly assigned 1 physician in each reminders. 

Was the treatment allocation concealed? X 

Were the groups similar at baseline regarding the most X important prognostic indicators? Was the outcome assessor blinded? NR Was the care provider blinded? NR Was the patient blinded? X Was the drop-out rate acceptable (≤ 20%)? [If between 20% NA and 60%, check other and explain.] Was the differential drop-out rate acceptable (≤ 15%)? NA 

Were co-interventions avoided or similar? X The interaction between the patient intervention and the ph

small, negative, and not statistically significant (−0.6%; 95% (P=.08), indicating that the observed effect of the combined reminders was 0.6% less than the sum of their effects when 

Were outcome measures valid, reliable, and equally applied? X Were all randomized participants analyzed in the group to X which they were originally assigned? Quality Rating (Good, Fair, or Poor): Good Applicability Assessment: Population Patients aged 50 to 80 years who had a visit with 1 of the 110 primary care physicians 

Intervention Patient mailings and physician reminders Comparison Compared Patients who received mailings and those who did not and patients of physicians who received remin

not. 

Outcomes Screening during the 15-month study period Timing of follow-up None Setting Clinic 

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Authors, ref ID: Stokamer, CL, Tenner, CT, Chaudhuri, J, Vazquez, E, & Bini, EJ 85 

STUDY: Year of publication: 2004 

Dates of data collection: 2002-2003 Trial name: To determine whether intensive patient education increases FOBT card return rates. 

OBJECTIVE OR AIM: 

Setting: primary care clinics at the VA New York Harbor Healthcare System in NYC, NY 

DESIGN: Study design: RCT 

Duration (mean followup): 6 months Overall study size (N enrolled/N analyzed): 794 referred/788 randomized/788 analyzed 

Intensive education Standard 

INTERVENTIONS: 396 392 

10-15 minutes educational session from 1 of 12 nurses: how to 

Sample size: perform FOBT; meaning of test results; what would happen if Written instructions on 

test positive or negative; Same instructions to re

2 page informational handout and to call with questioNurses answered questions 

Describe intervention: Instructed to return FOBT in 2 weeks and call with questions 

Health-system based 

RECRUITMENT: All patients referred to primary care nursing for patient education and distribution of FPBT 

this medical center) 

(population-based, clinic-based, 

volunteer, other) 

Age >=50 years old; outpatients in the primary care clinic; had an FOBT ordered by their h

INCLUSION CRITERIA: referred to primary care nursing for patient education and distribution for FOBT kits 

Refused participation 

EXCLUSION CRITERIA: 

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Authors, ref ID: Stokamer, CL, Tenner, CT, Chaudhuri, J, Vazquez, E, & Bini, EJ 85 

STUDY: Year of publication: 2004 

Dates of data collection: 2002-2003 Trial name: 

POPULATION CHARACTERISTICS: Mean age & range (years): Sex (% male): Race: Non-Hispanic white Non-Hispanic black Hispanic Other Other population qualities: 

• Family history of CRC 

Attrition/Drop-out (not available for 

endpoint measurement): 

Adherence in control group: Contamination in control group: 

Intensive 

67.0 (58.0-75.0) 

95.2% 

46.7 37.1 14.9 

1.3 7.1 

Standard 

67.0 (58.0-74.0) 

96.2% 

48.5 32.9 16.8 

1.8 6.1 

Intensive Standard 

0 0 

Not reported 

Note: Outcreturning Freturn the Fwere censoreturned. 

OUTCOME ASSESSMENT: Outcome Measures: 

Proportion of patients that returned FOBT cards within 6 months 

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Authors, ref ID: Stokamer, CL, Tenner, CT, Chaudhuri, J, Vazquez, E, & Bini, EJ 85 

STUDY: Year of publication: 2004 

Dates of data collection: 2002-2003 Trial name: 

RESULTS: KQ2 - What factors influence the use of NA 

colorectal cancer screening? 

KQ3 - Which strategies are effective in 

increasing the appropriate use of colorectal cancer screening and followup? 

KQ4 - What are the current and 

projected capacities to deliver colorectal cancer screening and surveillance at the population level? 

Outcomes: 

•	 Overall 462 of 788 participants returned FOBT cards in 6 months (58.6%): 

•	 A greater proportion of those with intensive education vs. standard returned the FOBT 

P < .001) 

NA 

KQ5 - What are the effective approaches NA 

for monitoring the use and quality of colorectal cancer screening? 

Fair 

QUALITY RATING: 

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Evidence Table 2. KQ 3: Which strategies are effective in increasing the appropriate use of colorectal cancer screening and su

Quality Assessment-Internal Validity for Controlled Trials Was the study described as randomized? 

Yes x 

No 

Was the method of randomization adequate? Was the treatment allocation concealed? 

x 

Were the groups similar at baseline regarding the most important prognostic indicators? x Was the outcome assessor blinded? 

x 

Was the care provider blinded? X Was the patient blinded? x Was the drop-out rate acceptable (≤ 20%)? [If between 20% and 60%, check other and explain.] X 

(58.6 %) 

Was the differential drop-out rate acceptable (≤ 15%)? x 

Were co-interventions avoided or similar? x Were outcome measures valid, reliable, and equally applied? X Were all randomized participants analyzed in the group to which they were originally assigned? X Quality Rating (Good, Fair, or Poor): Fair 

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Evidence Table 2. KQ 3: Which strategies are effective in increasing the appropriate use of colorectal cancer screening and su

Applicability Assessment 

Men in a NYC healthcare system; may not apply to women or to patients outside large city or in a differ

Population setting Intervention 

Intensive education on CRC screening and FOBT provided by a nurse; this might not be feasible for all 

At baseline, nurses provide FOBT kits to patients. Effect size would be even larger if standard practice 

Comparison kits to patients had been comparison. 

FOBT return rate is appropriate 

Outcomes 

6 month follow up appropriate for this study 

Timing of follow-up Setting 

Primary care setting is appropriate, however, the nature of the health care system and being in NYC ma

less generalizable 

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STUDY:	 Authors, ref ID: Tu SP, Taylor V, Yasui Y, Chun A, Yip MP, Acorda E, Li L, Bastani R. 86 

Year of publication: 2006 Dates of data collection: July 2003 – September 2004 Trial name: 

OBJECTIVE OR AIM: Evaluate a clinic-based, culturally and linguistically appropriate intervention promoting FO

DESIGN: Setting: International Community Health Services (ICHS), a community clinic serving pre

metropolitan area of Seattle, Washington. Study design: Randomized Controlled Trial Duration (mean followup): 6 months Overall study size (N enrolled/N analyzed): 210 

INTERVENTIONS: Intervention Control Sample size: Sample Size: 105 Sample Size: 105 

Intervention: Motivational video on Standard Care 

Describe intervention: CRC screening produced in 

Cantonese and dubbed into 

Mandarin, bilingual motivational 

pamphlet, an FOBT instruction 

sheet, bilingual CRC informational 

pamphlet, CRC screening 

education from a health educator, 

and an FOBT kit with instructions in 

Chinese and English. 

RECRUITMENT: Clinic-based; randomized those that agreed to participate using a randomization table to a

(population-based, clinic-based, chronological order to intervention or control status using a random number generator of R volunteer, other) INCLUSION CRITERIA: Age 50-78, spoke Cantonese, Mandarin and/or Chinese; patient for at least a year at ICH

EXCLUSION CRITERIA: 

Less than 12 months of medical care at ICHS; history of CRC; en-stage disease (e.g., conchronic obstructive pulmonary disease requiring oxygen), gastrointestinal symptoms requadherence to CRC screening (defined as FOBT in the past year or colonoscopy in the pasparticipation in qualitative interviews to discuss CRC screening. 

POPULATION CHARACTERISTICS: Group 1	 Group 2 

Intervention Control 

Mean age & range (years): 

Sex (% female): Age (50-78): 59.1% 50-64, 40.9% Age (50-78): 49.5% 50-64, 50.5% Race: 65+ 65+
 Other population qualities: Sex: 63.8% Female Sex: 61.9% female 

Race: Asian (Chinese) Race: Asian (Chinese) 

Language: 78.1% Cantonese, 21.0% Language: 79.1% Cantonese, 20.0% 

Mandarin, 0.9% English Mandarin, 0.9% English 

Insurance: 81.9% Public, 12.4% Insurance: 83.8% Public, 11.4% 

Private, 5.7% None Private, 4.8% None
 

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Evidence Table 2. KQ 3: Which strategies are effective in increasing the appropriate use of colorectal cancer screening and su

STUDY:	 Authors, ref ID: Tu SP, Taylor V, Yasui Y, Chun A, Yip MP, Acorda E, Li L, Bastani R. 86 

Year of publication: 2006 Dates of data collection: July 2003 – September 2004 Trial name: 

Group 1 Group 2	 

Attrition/Drop-out (not available for endpoint measurement): Adherence in control group: Contamination in control group: OUTCOME ASSESSMENT: Outcome Measures: 

FOBT screening within 6 months of randomization, based on chart audit by a study persopatients’ trial arm assignments. Only patients with 3 FOBT cards documented in their meconsidered as having completed FOBT screening. 

Results KQ2 - What factors influence the use of Outcomes: colorectal cancer screening? NA KQ3 - Which strategies are effective in increasing the appropriate use of colorectal cancer screening and followup? 

Outcomes: 

•	 69.5% of the intervention patients received FOBT screening, compared with 

Crude odds ratio for FOBT screening within 6 months of randomization by th5.98. 

•	 In logistic regression models adjusting for covariates, the odds of FOBT incr

greater in the intervention arm than in the control arm (AOR, 6.38; 95% CI, 3modification by age, gender, language, insurance, or prior FOBT was found

KQ4 - What are the current and Outcomes: 

projected capacities to deliver colorectal NA cancer screening and surveillance at the population level? KQ5 - What are the effective approaches Outcomes: for monitoring the use and quality of NA colorectal cancer screening?
 QUALITY RATING: Good 

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Evidence Table 2. KQ 3: Which strategies are effective in increasing the appropriate use of colorectal cancer screening and su

Quality Assessment-Internal Validity for Controlled Trials Was the study described as randomized? 

Yes X 

No 

Was the method of randomization adequate? X Was the treatment allocation concealed? 

CD 

Were the groups similar at baseline regarding the most important prognostic indicators? X Was the outcome assessor blinded? X Was the care provider blinded?

 NR 

Was the patient blinded? X Was the drop-out rate acceptable (≤ 20%)? [If between 20% and 60%, check other and explain.] Was the differential drop-out rate acceptable (≤ 15%)?

 NA 

Were co-interventions avoided or similar? Were outcome measures valid, reliable, and equally applied? X Were all randomized participants analyzed in the group to which they were originally assigned? X Quality Rating (Good, Fair, or Poor): Good
 

Applicability Assessment: Population Age (50-78), male/female, Chinese only
 Intervention Motivational video, bilingual motivational pamphlet, FOBT instruction sheet, bilingual CRC informational pamph

education from a health educator, and an FOBT kit 

Comparison Same pop with no intervention Outcomes FOBT screening rates Timing of follow-up Screening within 6 months of randomization Setting Clinic 

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Evidence Table 2. KQ 3: Which strategies are effective in increasing the appropriate use of colorectal cancer screening and su

Authors, ref ID: Zapka JG, Lemon SC, Puleo E, Estabrook B, Luckmann R, Erban S.87 

STUDY: Year of publication: 2004 

Dates of data collection: February 1999 – December 2000 Trial name: To test the effect of an educational video, mailed to patients’ homes before a physical exa

OBJECTIVE OR AIM: of colorectal cancer screening, particularly sigmoidoscopy. 

Setting: 5 primary care practices in central Massachusetts 

DESIGN: Study design: randomized, controlled trial 

Duration (mean followup): 6 months Overall study size (N enrolled/N analyzed): 938 scheduled for physical exam 

Intervention Group Control 

INTERVENTIONS: Sample size: 450 Sample size: 488 

Treatment: Video about CRC, importance of early Treatment: Usual care Sample size: detection, and screening options 

Describe intervention: 

Clinic-based; participants were recruited from 5 sites in central Massachusetts. Most wer

RECRUITMENT: medicine and family medicine clinics of an academic medical center. Computerized appo

potentially eligible participants 

(population-based, clinic-based, 

volunteer, other) 

Age 50 to 74; had an upcoming periodic health assessment; eligible for sigmoidoscopy ac

INCLUSION CRITERIA: guidelines 

No sigmoidoscopy within 5 years or colonoscopy within 10 years; recent or planned tests; 

EXCLUSION CRITERIA:	 sigmoidoscopy in the past 10 years; reported colorectal cancer diagnosis or related symp

examination appointment; could not participate because or illness, death, disability, or demwere institutionalized; do not speak English; had a spouse enrolled in the study; moved ou

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Evidence Table 2. KQ 3: Which strategies are effective in increasing the appropriate use of colorectal cancer screening and su

Authors, ref ID: Zapka JG, Lemon SC, Puleo E, Estabrook B, Luckmann R, Erban S.87 

STUDY: Year of publication: 2004 

Dates of data collection: February 1999 – December 2000 Trial name: 

Intervention Group Group 

POPULATION CHARACTERISTICS: Age: 290 age 50-64; 160 age over 65 Age: 322 age 50-64; 166 age ove

Sex: 56.7% female Sex: 56.4% female Insurance: 8.2% private, non-HMO; 52.8% private, Insurance: 5.5% private, non-HMOHMO; 12.5% Medicare, non-HMO; 20.3% Medicare, 10.5% Medicare, non-HMO; 19.5% 

Mean age & range (years): HMO; 6.2% Medicaid or other Medicaid or other 

Ever had FOB: 60.4% No Ever had FOB: 62.7% No 

Sex (% female): Race: Other population qualities: 

Group 1 Group 2 

20 were cdue to los

Attrition/Drop-out (not available for 

endpoint measurement): 

Adherence in control group: Contamination in control group: OUTCOME ASSESSMENT: Outcome Measures: 

Baseline and 4 to 6-month follow-up telephone assessments were conducted. Dependenscreening since baseline as 1) sigmoidoscopy with or without other tests, 2) another test o

tests. 

Results KQ2 - What factors influence the use of Outcomes: 

colorectal cancer NA screening? 

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Evidence Table 2. KQ 3: Which strategies are effective in increasing the appropriate use of colorectal cancer screening and su

Authors, ref ID: Zapka JG, Lemon SC, Puleo E, Estabrook B, Luckmann R, Erban S.87 

STUDY: Year of publication: 2004 

Dates of data collection: February 1999 – December 2000 Trial name: 

KQ3 - Which strategies are effective in 

increasing the appropriate use of colorectal cancer screening and followup? 

KQ4 - What are the current and 

projected capacities to deliver colorectal cancer screening and surveillance at the population level? 

G1: 55% overall screening rate G2: 55% screening rate Outcomes: NA 

KQ5 - What are the effective approaches Outcomes: 

for monitoring the use NA and quality of colorectal cancer screening? 

Good 

QUALITY RATING: 

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Evidence Table 2. KQ 3: Which strategies are effective in increasing the appropriate use of colorectal cancer screening and su

Quality Assessment-Internal Validity for Controlled Trials Was the study described as randomized? 

Yes X 

No 

Was the method of randomization adequate? X Was the treatment allocation concealed? X Were the groups similar at baseline regarding the most important prognostic indicators? X Was the outcome assessor blinded? X Was the care provider blinded? X Was the patient blinded? X Was the drop-out rate acceptable (≤ 20%)? [If between 20% and 60%, check other and explain.] X Was the differential drop-out rate acceptable (≤ 15%)? X 

Were co-interventions avoided or similar? Were outcome measures valid, reliable, and equally applied? X Were all randomized participants analyzed in the group to which they were originally assigned? X Quality Rating (Good, Fair, or Poor): Good Applicability Assessment 

Age 50+, both sexes 

Population 

Video about CRC, importance of early detection, and screening options 

Intervention 

Usual care 

Comparison 

CRC screening 

Outcomes 

Baseline and 4 to 6-month follow-up telephone assessments were conducted. 

Timing of follow-up 

Clinic 

Setting 

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Evidence Table 3. KQ 4: Current and projected capacity to deliver colorectal cancer screening and surveillance 

STUDY:	 Authors, ref ID: Ballew et al.88 

Year of publication: 2009 Dates of data collection: March May 2008 Trial name: NA 

OBJECTIVE OR AIM: Montana Department of Public Health and Human Services wanted to assess the colonos

before embarking on a campaign to increase colorectal screening participation statewide. 

DESIGN: Setting: Montana 

Study design: Hospital survey Duration (mean follow-up): No follow-up Overall study size (N enrolled/N analyzed): 41 hospitals, 3 ambulatory surgical centers 

Group 

Sample size: Sample size: 41 hospitals, 3 

ambulatory surgical centers 

Describe intervention: Intervention: None, 8-question 

survey about current and projected screening capacity 

RECRUITMENT: All hospitals and ambulatory surgical centers in Montana (population-based, clinic-based, volunteer, other) INCLUSION CRITERIA: Perform colonoscopy EXCLUSION CRITERIA: NA POPULATION CHARACTERISTICS:	 NA 

Mean age & range (years): Sex (% female): Race: Other: 

1 hospital did not respond 

Attrition/Drop-out (not available for 

endpoint measurement): Adherence:
 Contamination: Response Rates (e.g. for surveys): STATISTICAL ANALYSES: Collected data on CRC screening capacity and ran comparative statistics ASSESSMENT OF EXPOSURES AND NR POTENTIAL CONFOUNDERS: OUTCOME ASSESSMENT: Outcome Measures: 

CRC screening capacity 

RESULTS: 
Evidence Table 3. KQ 4: Current and projected capacity to deliver colorectal cancer screening and surveillance (continued) 

STUDY:	 Authors, ref ID: Ballew et al.88 

Year of publication: 2009 Dates of data collection: March May 2008 Trial name: NA 

KQ2 - What factors influence the use of NA colorectal cancer screening? KQ3 - Which strategies are effective in NA increasing the appropriate use of colorectal cancer screening and followup? KQ4 - What are the current and projected capacities to deliver colorectal cancer screening and surveillance at the population level? 

Outcomes: 

•	 In the aggregate, hospitals performed 36,636 colonoscopies per year, includ

procedures (54% of total procedures, range 11% to 100%). Hospitals estima23,096 more screening colonoscopies per year. 

•	 The number of Montana adults who need screening colonoscopy was estim

increasing to 159,863 in 2020. Assuming that all unscreened individuals dem10 years, and utilizing 100% of hospitals’ estimated screening capacity, full scolonoscopy could be achieved by 2013. 

There was an uneven distribution of current volume and additional available capacity in Mprimarily rural state. Urban hospitals had more resources but also less additional available capacity. 35% of the population lived in urban areas where 49% of the total capacity was located buunused capacity was located. 65% of the population lived in rural areas where 51% of thwhere 76% of unused capacity was located. 

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KQ5 - What are the effective approaches Outcomes: for monitoring the use and quality of NA colorectal cancer screening?
 QUALITY RATING: Fair 
Evidence Table 3. KQ 4: Current and projected capacity to deliver colorectal cancer screening and surveillance (continued) 

Quality Assessment-Internal Validity for Observational Studies Were the groups similar at baseline regarding the most important prognostic indicators? 

Yes No Other (CD, NR, N

NA 

Were the drop-out or response rates acceptable (≤ 20%)? [If between 20% and 60%, check other X 

and explain.] Were the differential drop-out or response rates acceptable (≤ 15%)? NA Were intervention/exposure measures valid, reliable, and equally applied? NA Were the outcome assessors blinded to the intervention or exposure status of subjects? NA 

Were outcome measures valid, reliable, and equally applied? X Does the analysis control for baseline differences? NA Were important potential confounding and modifying variables taken into account in the design and analysis (e.g., through matching, stratification, or statistical adjustment)? Were the statistical methods used to assess the abstracted outcomes appropriate? X 

Quality Rating (Good, Fair, or Poor): Fair 

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Evidence Table 3. KQ 4: Current and projected capacity to deliver colorectal cancer screening and surveillance (continued) 

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STUDY:	 Authors, ref ID: Benuzillo JG, Jacobs ET, Hoffman RM, Heigh RI, Lance P, Martinez ME8

Year of publication: 2009 Dates of data collection: 2004 Trial name: Rural urban differences in colorectal cancer screening capacity in Arizona 

OBJECTIVE OR AIM: The aims of this work were to evaluate current colorectal cancer endoscopy screening cap

potential volume for rural and urban regions in Arizona. 

DESIGN: Setting: Arizona clinics 

Study design: Observational cohort study Duration (mean followup): No follow-up, one-time survey Overall study size (N enrolled/N analyzed): 105 gastroenterologists and colorectal surge

All 

Sample size: Sample size: 105 gastroenterologists and colorectal 

surgeons 

Describe intervention: Intervention: Survey that assessed current 

colonoscopy and sigmoidoscopy screening and estimated future capacity. 

RECRUITMENT: Population-based (population of gastroenterologists and colorectal surgeons; membership 

(population-based, clinic-based, specialist professional societies to identify gastroenterologists and colorectal surgeons pravolunteer, other) names of the societies were not given. INCLUSION CRITERIA: Physicians who indicated that they performed lower gastrointestinal endoscopies for colore

How this was determined was not specified. 

EXCLUSION CRITERIA:	 Other health care professionals, such as hepatologists, pathologists, and nurses with a sha

of patients with digestive diseases but who typically do not perform lower endoscopic screeexcluded. Not clear whether they were not sampled or were excluded from the sample. 

POPULATION CHARACTERISTICS:	 All 

Age range: 30-67 

Mean age & range (years): Sex: 26.7% female Sex (% female): Specialty: 90% gastroenterology Race: Other: 

All Group 2 

Attrition/Drop-out (not available for 338 identified to receive the survey; 104 not endpoint measurement): performing endoscopy or not practicing in AZ Adherence: Therefore, 234 eligible physicians Contamination: received the mailed surveys and of these, 105 

were returned, resulting in a response rate of 

Response Rates (e.g. for surveys): 44.9% STATISTICAL ANALYSES: Describe: 

Standard descriptive statistics, including means and medians, were used to analyze these 

stratified according to rural/urban areas. 
Evidence Table 3. KQ 4: Current and projected capacity to deliver colorectal cancer screening and surveillance (continued) 

STUDY:	 Authors, ref ID: Benuzillo JG, Jacobs ET, Hoffman RM, Heigh RI, Lance P, Martinez ME8

Year of publication: 2009 Dates of data collection: 2004 Trial name: Rural urban differences in colorectal cancer screening capacity in Arizona 

ASSESSMENT OF EXPOSURES AND Authors compared survey responses by rural and urban regions in Arizona using the 2003 

POTENTIAL CONFOUNDERS: Agriculture Rural–Urban Continuum Codes. For the present analyses, authors categorized 

corresponding to the metropolitan codes as urban and the remaining non-core counties as 

OUTCOME ASSESSMENT: Outcome Measures: 

The Colon Cancer Screening Capacity Survey was modified from an instrument used to sugastroenterologists. The ten questions included in the original survey were created based oBehavioral Risk Factor Surveillance System’s (BRFSS) survey, and the experience of resefrom New Mexico. Survey respondents were asked to report their average number of endoperformed during a week and to estimate the number of additional procedures that could b

RESULTS: KQ2 - What factors influence the use of NA colorectal cancer screening? KQ3 - Which strategies are effective in NA increasing the appropriate use of colorectal cancer screening and followup? 

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 KQ4 - What are the current and 

projected capacities to deliver colorectal cancer screening and surveillance at the population level? 

Outcomes: 

•	 The average number of weekly colonoscopies and sigmoidoscopies per endo

respectively. When data were stratified by physician type, the median numbecolonoscopies was 20 (interquartile range, 15–25) for gastroenterologists and 10–20) for colorectal surgeons. Colorectal surgeons performed a median of 5 sigmoidoscopies a week (interquartile range, 2–10) compared to a median of 0–2) procedure performed by gastroenterologists. 

•	 Overall, physicians reported performing 8,717 weekly endoscopic procedures 

405 in rural areas). The vast majority of the procedures were colonoscopies iurban and 97% in rural areas).Responders estimated being able to increase additional 3,183 (36.5%) procedures per week (2,347 colonoscopies and 836 sigmoidoscopies). While only 5% of all procedures were performed in rural arthat the potential increase in volume is greater for rural than urban areas (53.respectively). This is an important finding given that rates of endoscopic scre(49.5%; 95% confidence interval [CI] 46.8–52.2) compared to urban areas (557.5). 

•	 Among all respondents, more physicians was most commonly cited as the re

needed to increase capacity (49.5%); although this was the most common rephysicians (52.1%), rural doctors noted appropriate compensation as the top Further, urban physicians more frequently cited the need for additional resou
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Evidence Table 3. KQ 4: Current and projected capacity to deliver colorectal cancer screening and surveillance (continued) STUDY:	 Authors, ref ID: Benuzillo JG, Jacobs ET, Hoffman RM, Heigh RI, Lance P, Martinez ME8

Year of publication: 2009 Dates of data collection: 2004 Trial name: Rural urban differences in colorectal cancer screening capacity in Arizona 

staff, to meet capacity than their rural counterparts. A total of 27.3% of rural pthey needed no additional resources to increase their endoscopic capacity wurban practitioners did so. 

KQ5 - What are the effective approaches for monitoring the use and quality of colorectal cancer screening? QUALITY RATING: 

NA Fair 

Quality Assessment-Internal Validity for Observational Studies Were the groups similar at baseline regarding the most important prognostic indicators? 

Yes No Other (CD, NR, N

NA 

Were the drop-out or response rates acceptable (≤ 20%)? [If between 20% and 60%, check other and explain.] Were the differential drop-out or response rates acceptable (≤ 15%)? 

Were intervention/exposure measures valid, reliable, and equally applied? Were the outcome assessors blinded to the intervention or exposure status of subjects? Were outcome measures valid, reliable, and equally applied? Does the analysis control for baseline differences? Were important potential confounding and modifying variables taken into account in the design and analysis (e.g., through matching, stratification, or statistical adjustment)? Were the statistical methods used to assess the abstracted outcomes appropriate? Quality Rating (Good, Fair, or Poor): Fair 

X 

X 

X 

X Response rate 44

NA 

NA NA NA 
Evidence Table 3. KQ 4: Current and projected capacity to deliver colorectal cancer screening and surveillance (continued) 

STUDY: Current capacity for endoscopic Authors, ref ID: Brown et al.90 colorectal cancer screening in the United Year of publication: 2003 

States: data from the National Cancer Dates of data collection: November 1999 – April 2000 Institute survey of colorectal cancer Trial name: Data from Survey of Colorectal Cancer Screening Practices 

screening practices OBJECTIVE OR AIM: The purpose of this study was to provide nationally representative data on endoscopic res

level. 

DESIGN: Setting: United States 

Study design: cross-sectional mailed survey + modeling study Duration (mean follow-up): NA Overall study size (N enrolled/N analyzed): 1235 primary care physicians, 349 gastroensurgeons (see response rates below) 

Sample size: 1630 primary care physicians, 467 

GI, 467 general surgeons 

Describe intervention:	 NA 

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RECRUITMENT: Used survey data collected in 1999 – 2000. Physicians approached for this survey were i(population-based, clinic-based, American Medical Association’s Physician Masterfile. volunteer, other) INCLUSION CRITERIA: Little detail given. For more information, reader is referred to: 

http://healthservices.cancer.gov/surveys/colorectal/ 

EXCLUSION CRITERIA: NR POPULATION CHARACTERISTICS:
 

Mean age & range (years): Sex (% female): Race: Other: 

Characteristics of respondents and their practice setting, Survey of Colorectal Cancer Scr2000 

Characteristic Male sex White, non-Hispanic Board certified IMG Age ≥ 50 years Metropolitan location Practice type Solo Single-specialty  Multispecialty Practice volume (per week) > 50 patients 

Primary care (n = Gastroenterolgists (n = 

1235) 349) 

 Number (%) 

960 (77.7) 324 (92.8) 

894 (72.4) 279 (79.8) 

921 (74.6) 325 (93.1) 277 (22.4) 72 (20.6) 

589 (47.7) 109 (31.2) 

751 (60.8) 252 (72.2) 

316 (25.6) 78 (22.0) 

508 (41.1) 168 (48.2) 

411 (33.3) 103 (29.5) 

548 (44.4) 102 (29.2) 
Evidence Table 3. KQ 4: Current and projected capacity to deliver colorectal cancer screening and surveillance (continued) 

STUDY: Current capacity for endoscopic Authors, ref ID: Brown et al.90 colorectal cancer screening in the United States: data from the National Cancer 

Year of publication: 2003 Dates of data collection: November 1999 – April 2000 

Institute survey of colorectal cancer Trial name: Data from Survey of Colorectal Cancer Screening Practices screening practices 

 > 100 patients 441 (35.7) 39 (11.0) 

> 50% of patients covered 760 (61.5) 141 (40.5) 

by managed care 

Attrition/Drop-out (not available for 

endpoint measurement): Adherence:
 Contamination: Response Rates (e.g. for surveys): 

The authors obtained 1235responses to the primary care survey, a response rate of 72%, survey (349 gastroenterologists, 316 general surgeons),a response rate of 83%. 

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STATISTICAL ANALYSES: The authors calculated means, proportions, and 95% confidence intervals based on weigh

probability of selection into the sample, and adjusted for known sources of respondent biaresponse rates, weighted and unweighted results were very similar.) In addition, the authoto obtain estimates of national endoscopy requirements implied by various programmatic cancer screening. MISCAN-COLON is a microsimulation model that takes into account naand assumptions about screening test performance characteristics and screening program including the frequency of screening, diagnostic, and surveillance procedures . The authoof average risk persons would occur from ages 50 to 80 years; that 70% of the population screening; and that if someone attended a screening, he or she had a 90% probability of a

screening, whereas if someone did not attend a screening, he or she had a 20% probabiliscreening. The authors further assumed a test positivity rate of 2% for fecal occult blood t

of a polyp _5 mm, a person was returned to routine screening; and that after discovery of received surveillance colonoscopy once every 5 years until no lesions were found. 

ASSESSMENT OF EXPOSURES AND NA POTENTIAL CONFOUNDERS: OUTCOME ASSESSMENT: The authors used items from the primary care and GI/general surgeon questionnaires tha

FS and colonoscopy procedures performed in a typical month during the survey period. Sdefined as the use of a procedure to detect cancer or neoplasia in an asymptomatic patiewas defined as use in patients with symptoms or previously abnormal test results. Readers are referred to further details at: http://healthservices.cancer.gov/surveys/colorecare downloadable here, but no further detail on methods is given. 

RESULTS: KQ2 - What factors influence the use of NA colorectal cancer screening? KQ3 - Which strategies are effective in NA increasing the appropriate use of colorectal cancer screening and follow-
Evidence Table 3. KQ 4: Current and projected capacity to deliver colorectal cancer screening and surveillance (continued) 

STUDY: Current capacity for endoscopic Authors, ref ID: Brown et al.90 colorectal cancer screening in the United Year of publication: 2003 States: data from the National Cancer Dates of data collection: November 1999 – April 2000 Institute survey of colorectal cancer Trial name: Data from Survey of Colorectal Cancer Screening Practices screening practices up? KQ4 - What are the current and Reported volume of endoscopy procedures by physician specialty projected capacities to deliver colorectal cancer screening and surveillance at the population level? 

Physicians in the United States Sigmoidoscopy procedures/ month 0 1 – 5 6 – 10 11 – 20 > 20 Other Estimated total procedures in the U.S. Screening colonoscopy procedures/month 0 1 – 5 6 – 10 11 – 20 > 20 Other Total procedures in the U.S. Diagnostic colonoscopy procedures/ month 0 1 – 5 6 – 10 11 – 20 > 20 Other Total procedures in the U.S.  Physician Specialty 

Primary care (n = 1235) Gastroenterology (n = 156,605 1.9 ± 4.3 

871 (71) 

203 (17) 

95 (7) 

38 (3) 

17 (1) 

11 (1) 

3,205,000 (64.8) 

0.1 ± 1.1 

1182 (96) 

30 (2) 

23 (2) 

9100 (0.6) 

346) 

7,835 

Number (%) or Mean ± SD 

14.2 ± 39.3 

14 (4) 47 (14) 76 (22) 88 (25) 

107 (31) 

14 (4) 

1,224,000 (24.7) 

12.4 ± 40.2 

19 (5) 

71 (21) 

83 (24) 

74 (21) 

89 (26) 10 (3) 

1,071,000 (66.3) 

19.5 ± 33.0 

8 (2) 

11 (3) 

29 (8) 97 (28) 193 (56) 

8 (2) 

1,678,000 (69.6) 

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Evidence Table 3. KQ 4: Current and projected capacity to deliver colorectal cancer screening and surveillance (continued) 

STUDY: Current capacity for endoscopic Authors, ref ID: Brown et al.90 colorectal cancer screening in the United Year of publication: 2003 States: data from the National Cancer Dates of data collection: November 1999 – April 2000 Institute survey of colorectal cancer Trial name: Data from Survey of Colorectal Cancer Screening Practices screening practices 

Approximately 4.9 million sigmoidoscopies in 2000, 1.6 million screening colonoscopies, a

plus diagnostic) colonoscopies were performed. On averaqe, general surgeons performed about 8 colonoscopies per month, compared w

gastroenterologists11 of 11 group practices 9 or 12 solo practitioners Current capacity compared to projected national requirements The authors estimated national requirements for endoscopy associated with programs of based on fecal occult blood testing, with or without sigmoidoscopy or colonoscopy, as the under the counterfactual assumption that population usage levels of colorectal cancer scrcurrent rates for screening mammography of 70% of eligible women. Under this assumptisigmoidoscopy once every 5 years would require the delivery of almost 10 million flexible 

in 2000, about twice the number of sigmoidoscopy procedures currently performed. Scree

performed once every 10 years would require, under very conservative assumptions, the 

screening and surveillance colonoscopy procedures in 2000, about 20% more than the esprocedures that were performed for all purposes in 2000. From discussion: the authors estimated that a national program of colorectal cancer screecolonoscopy would have required about 4.8 million procedures in 2000, about 20% more million procedures that were performed for all purposes in 2000. Alternatively, a screenin

same level of population use based on annual fecal occult blood testing would have requimillion diagnostic and surveillance colonoscopies; sigmoidoscopy once ever y 5 years womillion colonoscopy procedures and a program of combined fecal occult blood testing and have required about 2.6 million procedures in 2000. 

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KQ5 - What are the effective approaches NA for monitoring the use and quality of colorectal cancer screening? QUALITY RATING: Good 
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Evidence Table 3. KQ 4: Current and projected capacity to deliver colorectal cancer screening and surveillance (continued) Quality Assessment-Internal Validity for Observational Studies Were the groups similar at baseline regarding the most important prognostic indicators? 

Yes No Other (CD, NR

NA 

Were the drop-out or response rates acceptable (≤ 20%)? [If between 20% and 60%, check other and X Yes, report res

explain.] than 70% Were the differential drop-out or response rates acceptable (≤ 15%)? X 72% response 

83% for GI and 

Were intervention/exposure measures valid, reliable, and equally applied? X Measurement 

procedures cap

Were the outcome assessors blinded to the intervention or exposure status of subjects? NA 

Were outcome measures valid, reliable, and equally applied? X Self reported c

Does the analysis control for baseline differences? NA Were important potential confounding and modifying variables taken into account in the design and analysis (e.g., through matching, stratification, or statistical adjustment)? Were the statistical methods used to assess the abstracted outcomes appropriate? Were data inputs valid? Limited inputs 

references. Loeve F, Boer et al. The MISCsimulation modcolorectal cancComput Biome13. Loeve F, BEndoscopic coscreening: a co

Cancer Inst. 20563. This article desdata inputs. 

Was an appropriate search strategy used to find data inputs? Were the calculations and statistical analyses adequate? Not clear how 

applied take in

Were appropriate sensitivity analyses conducted (especially for any variables that were not based on 

X 

data from literature)? Other considerations: [These might include the following for various types of models: was the cost effectiveness analysis conducted from the societal perspective? Was an appropriate comparison used (standard of care or next most effective alternative)? Were the appropriate health benefits, harms, and costs described and included?] Quality Rating (Good, Fair, or Poor): Fair 
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Evidence Table 3. KQ 4: Current and projected capacity to deliver colorectal cancer screening and surveillance (continued) STUDY: Colonoscopy Demand and Authors, ref ID: Butterly et al.91 Capacity in New Hampshire	 Year of publication: 2007 

Dates of data collection: 2003-2004 Trial name: NA 

OBJECTIVE OR AIM: Evaluate the demand and capacity for colonoscopy in the state of New Hampshire. 

DESIGN: Setting: All endoscopy sites in NH contacted in 2003-2004 

Study design: Observational Duration (mean follow-up): 

Sample size: Overall study size (N enrolled/N analyzed): 114 endoscopists at 36 centers 

Endoscopists 62 (54.4%) gastroenterologists 45 (39.5%) general or colorectal surgeons 3 (2.6% FP) or GIM docs 4 other 

Describe intervention: NA RECRUITMENT: All endoscopy sites in NH contacted. Two-phase telephone interview: The 1st phase had q

(population-based, clinic-based, capacity and limitations to performing colonoscopies, # of colonoscopies done/week, descvolunteer, other) processes, and barriers to increasing capacity. In the 2nd phase, sites were recontacted to 

of colonoscopies for 2002. 

INCLUSION CRITERIA: All endoscopy sites in the state of New Hampshire EXCLUSION CRITERIA: All others POPULATION CHARACTERISTICS: NA Response Rates (e.g. for surveys): Phase 1: not described 

Phase 2: all sites but one 

DATA INPUTS/Outcome assessment	 Total # of colonoscopies reported per week (currently), including an estimate of the numb

vs. diagnostic or therapeutic Number of colonoscopies conducted in 2002: calculated from procedure logs for the year all forms of colonoscopy For colonoscopies done in hospital settings (with the exception of the VA), #s were compaHampshire Hospital Association (NHHA) Of the 36 sites, nine sites were free-standing ambulatory surgical centers not associated w

validating results from these sites was available To estimate demand, Census 2000 data obtained from the NH Office of State Planning. E

individuals at increased risk as well as those at average risk. Demand equals all individuasurveillance according to current guidelines. Estimated 30% increased risk and 65% at avrisk population was assumed to require surveillance intervals of 5 years. 
Evidence Table 3. KQ 4: Current and projected capacity to deliver colorectal cancer screening and surveillance (continued) 

STUDY: Colonoscopy Demand and Authors, ref ID: Butterly et al.91 Capacity in New Hampshire	 Year of publication: 2007 

Dates of data collection: 2003-2004 Trial name: NA 

STATISTICAL ANALYSES: Analysis of demand was modeled according to three compliance rates of 100%, 70% and 

was applied to population statistics for the years 2002, 2005, and 2010. Two proposed methods of improving capacity are to increase the percentage of current coscreening and to increase capacity itself. Capacity was therefore calculated for 40%, 50%of colonoscopy being devoted to screening, and the potential increase in capacity if knowby 10% and 20%. For the latter estimates, it was assumed that all of the 10% and 20% in

devoted to screening. 

RESULTS: 

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KQ4 - What are the current and projected capacities to deliver colorectal cancer screening and surveillance at the population level? 

114 endoscopists at 36 centers performed 49,352 colonoscopies in 2002, an average of 3

60% of these estimated to have been done for CRC screening. To confirm the accuracy of the colonoscopy numbers, results were compared to the NHAA 32,802 colonoscopies were performed in NH between 7/1/01 and 6/30/02. To adjust for t

the total for centers that would be included in the NHAA database was calculated: 32,987Estimated demand was approximately twice the available capacity for screening and survThe primary factor reported to limit capacity was # of endoscopists (72% of centers), # of centers), and # of available endoscopy nurses and support staff (50% of centers). Demand for screening and surveillance colonoscopies per year by population 

 2002 2005 

Population aged >50 y 364,108 425,539 65% avg. risk 23,667 27,660 

35% increased risk 25,487 29,788 

Total 49,154 57,448 

Potential increase in colonoscopy screening capacity varied by % of colonoscopies condu

Total # of 40% screening 50% screening 60% screening colonoscopes Total in 2002 19,741 24,676 29,611 (49,352) If increase capacity 24,676 29,611 34,546 by 10% (54,287) If increase capacity 29,611 34,546 39,481 by 20% (59,222) 
Evidence Table 3. KQ 4: Current and projected capacity to deliver colorectal cancer screening and surveillance (continued) 

STUDY: Colonoscopy Demand and Authors, ref ID: Butterly et al.91 Capacity in New Hampshire	 Year of publication: 2007 

Dates of data collection: 2003-2004 Trial name: NA 

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49,325 colonoscopies performed in 2002. If the capacity was increased by 10%, this woucolonoscopies/year to 54,287. If this capacity were increased by 20%, this would increascolonoscopies/year to 59,222 Annual demand for screening and surveillance c-scope adjusted for varying compliance ra

 2002 2005 100% compliance 49,154 57,448 70% compliance 34,408 40,214 

60% compliance 29,493 34,469 

Note top line of this table is the same as the totals in the 1st table above 

If capacity increases by 20%, at the current rate of 60% of procedures for screening, and rate, capacity would almost meet demand. Monthly figure of 39-43 colonoscopies per months is similar to the results from NCI study. 20/week. 

QUALITY RATING: Fair 
Evidence Table 3. KQ 4: Current and projected capacity to deliver colorectal cancer screening and surveillance (continued) 

Quality Assessment-Internal Validity 

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Did the authors report conducting a power analysis or some other basis for determining the adequacy of study group sizes for the outcome(s) being abstracted? Were the groups similar at baseline regarding the most important prognostic indicators? Were the drop-out or response rates acceptable? Were the differential drop-out or response rates acceptable? Were co-interventions avoided or similar? 

Yes No 

Were intervention/exposure measures valid, reliable, and equally applied? Were the outcome assessors blinded to the intervention or exposure status of subjects? 

Were outcome measures valid, reliable, and equally applied? X 

Were all participants analyzed in the group to which they were originally assigned? Does the analysis control for baseline differences? Were important potential confounding and modifying variables taken into account in the design and analysis (e.g., through matching, stratification, or statistical adjustment)? Were the statistical methods used to assess the abstracted outcomes appropriate? Were data inputs valid? Was an appropriate search strategy used to find data inputs? Were the calculations and statistical analyses adequate? Were appropriate sensitivity analyses conducted (especially for any variables that were not based on data from literature)? Other considerations: [These might include the following for various types of models: was the cost effectiveness analysis conducted from the societal perspective? Was an appropriate comparison used (standard of care or next most effective alternative)? 

Were the appropriate health benefits, harms, and costs described and included?] Quality Rating: Fair 

X 

X 

X 

X 
Evidence Table 3. KQ 4: Current and projected capacity to deliver colorectal cancer screening and surveillance (continued) 

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STUDY: New Mexico’s capacity for Authors, ref ID: Hoffman et al.92 increasing the prevalence of colorectal Year of publication: 2005 

cancer screening with screening Dates of data collection: October – December 2001 

colonoscopies	 Trial name: Colorectal Cancer Working Group of the Clinical Prevention Initiative (CPI) 

OBJECTIVE OR AIM: The authors evaluate New Mexico’s capacity to increase the prevalence of colorectal canc

colonoscopy. 

DESIGN: Setting: New Mexico endoscopists 

Study design: Descriptive, cross-sectional and modeling Duration (mean follow-up): One-time survey Overall study size (N enrolled/N analyzed): Survey information collected from 9/12 solo group practices representing 40 endoscopists (2-8 practitioner / group) 

Sample size: 9 solo practitioners and 11 group practices representing 40 endoscopists NA 

Describe intervention: RECRUITMENT: The authors The authors identified endoscopists in New Mexico by using data from the Bo(population-based, clinic-based, contacting manufacturers of endoscopic equipment, and obtaining the membership lists o

volunteer, other) gastroenterology journal club, the New Mexico Medical Society, and the American Medica

subjects for this analysis were gastroenterologists actively practicing in New Mexico, whicgastroenterologists practicing in one of the 11 group practices and 12 solo practitioners. 

INCLUSION CRITERIA: Gastroenterologists actively practicing in New Mexico EXCLUSION CRITERIA: POPULATION CHARACTERISTICS:	 Physicians and practices were based in 12 different counties 

10/11 group practices and 6/12 solo practitioners were in urban areas 

Mean age & range (years): 

Sex (% female): Race: Other: Attrition/Drop-out (not available for 11 of 11 group practices endpoint measurement): 9 or 12 solo practitioners Adherence:
 Contamination: Response Rates (e.g. for surveys): STATISTICAL ANALYSES: The authors used descriptive nonparametric statistics to estimate the weekly median num

performed by endoscopists in group practice and solo practice and the estimated weekly capacity. Endoscopic capacity. The authors determined the number of additional screening colonoscopies that could be presponses. Responses were averaged when multiple members of a group practice compprovided different estimates for the weekly number of baseline and additional procedures The weekly number of base-line and additional colonoscopies for the solo-practitioner non
Evidence Table 3. KQ 4: Current and projected capacity to deliver colorectal cancer screening and surveillance (continued) 

STUDY: New Mexico’s capacity for Authors, ref ID: Hoffman et al.92 increasing the prevalence of colorectal Year of publication: 2005 cancer screening with screening Dates of data collection: October – December 2001 colonoscopies Trial name: Colorectal Cancer Working Group of the Clinical Prevention Initiative (CPI) 

using data from the responding solo practitioners. For the annual number of colonoscopieendoscopists performed procedures for 40 weeks. Similar estimates were performed for tsigmoidoscopies. Volume of colonoscopies. The authors modeled the number of procedures required for a statewide screening colonothe number of subjects potentially eligible for colonoscopic screening, they used data from Census for New Mexico that reported 468,000 resident adults aged 50 to 85. Based on thevaluated the additional number of screening colonoscopies required to increase the prevby 5% (23,400 additional people being screened), 10% (46,800), 15% (70,200), 20% (93,during a five-year period. The authors assumed that the additional screening procedures w

equal numbers during the five-year period. The authors then modeled the number of survewould be required following the initial screening colonoscopy, and used clinical data on th

cancers and adenomatous polyps from a recent, large Department of Veterans Affairs (VAtrial and consensus guidelines for the timing of surveillance procedures. A sensitivity analysis was performed by reducing the expected rates of detected colorectaadenomatous polyps by approximately 50%. 

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 ASSESSMENT OF EXPOSURES AND NA POTENTIAL CONFOUNDERS: 

OUTCOME ASSESSMENT: The CPI colorectal cancer group developed a brief survey to obtain information about end

colonoscopies and flexible sigmoidoscopies. Questions were based on literature review, texperience of the CPI colorectal cancer group, which included two gastroenterologists and performed sigmoidoscopy. Revisions were based on pilot testing the survey with clinical cmembers of the CPI. 

RESULTS: KQ2 - What factors influence the use of NA colorectal cancer screening? KQ3 - Which strategies are effective in NA increasing the appropriate use of colorectal cancer screening and followup? KQ4 - What are the current and projected capacities to deliver colorectal cancer screening and surveillance at the population level? 

# of procedures currently being performed weekly and the weekly capacity for additional ptype of practice 

Practice type Total # Current c- Total current c- Weekly ca

endoscopists scopes/ scopes for additio

endoscopist* procedure

Group 40 16.3 (12.9, 652 6.3 (1.8, 1

26.50 
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Evidence Table 3. KQ 4: Current and projected capacity to deliver colorectal cancer screening and surveillance (continued) STUDY: New Mexico’s capacity for Authors, ref ID: Hoffman et al.92 increasing the prevalence of colorectal Year of publication: 2005 cancer screening with screening Dates of data collection: October – December 2001 colonoscopies Trial name: Colorectal Cancer Working Group of the Clinical Prevention Initiative (CPI) 

Solo 9 20 (15, 21) 180 10 (5, 15) 

combined 49 NA 832 NA 

*values are median (interquartile range) Overall, gastroenterologists reported performing 832 colonoscopies a week. They estimattheir capacity by an additional 342 (41%) procedures each week. Statewide, endoscopists could perform an estimated 13,680 additional colonoscopic procenonresponding solo practitioners performed similarly to those completing the survey, the ecapacity for colonoscopy would be 14,880 procedures. Number of c-scopes required to increase the prevalence of current screening during a 5-yaged 50 – 85 years 

Screening increase over 5 years Annual # of c-scopes (based on Annual # o(%) detection rates from VA study)a detection 

analysis) b 

5 5568 (5983)* 5137 (536

10 11,136 (11,966) 10,274 (10

15 16,704 (17,949) 15,411 (16

20 22,272 (23,932) 20,548 (2

25 27,840 (29,915) 25,568 (26

a Includes numbers of screening tests based on 2000 New Mexico census data and numb

based on applying cancer (1.0%) and adenomatous polyp (37%) detection rates from a DAffairs (VA) study.b Includes numbers of screening tests based on 2000 New Mexico cens

surveillance tests based on applying cancer (0.5%) and adenomatous polyp (20%) detectanalysis. *Numbers in parentheses reflect the strategy of performing a three-year surveillance colonadenomatous polyps compared to five- year surveillance interval. All but one of the group practices performed flexible sigmoidoscopies, but only five of the performed them. Overall, however, only 165 procedures were performed weekly; respondcould perform an additional 188 procedures. New Mexico gastroenterologists responding to the survey estimated having the capacity tnumber of colonoscopies by about 41%, from 832 to 1174. This substantial increase could current endoscopic screening by approximately 15% within five years. 

KQ5 - What are the effective approaches NA for monitoring the use and quality of colorectal cancer screening? 
Evidence Table 3. KQ 4: Current and projected capacity to deliver colorectal cancer screening and surveillance (continued) 

STUDY: New Mexico’s capacity for Authors, ref ID: Hoffman et al.92 increasing the prevalence of colorectal Year of publication: 2005 cancer screening with screening Dates of data collection: October – December 2001 colonoscopies Trial name: Colorectal Cancer Working Group of the Clinical Prevention Initiative (CPI) 

QUALITY RATING: Fair Quality Assessment-Internal Validity for Observational Studies 

Yes No 

Were data inputs valid? X Was an appropriate search strategy used to find data inputs? X Were the calculations and statistical analyses adequate? X 

Were appropriate sensitivity analyses conducted (especially for any variables that were not based on data from X literature)? Other considerations: 

X 

[These might include the following for various types of models: was the cost effectiveness analysis conducted from the societal perspective? Was an appropriate comparison used (standard of care or next most effective alternative)? 

Were the appropriate health benefits, harms, and costs described and included?] Quality Rating (Good, Fair or Poor): Fair 

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Evidence Table 3. KQ 4: Current and projected capacity to deliver colorectal cancer screening and surveillance (continued) 

STUDY:	 Authors: Hur et al.93 

Year: 2004 Trial name (if applicable): 

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DESIGN: Study design: Mathematical model 

Number of subjects: NA Time period covered: 5 years 

QUESTIONAIM/OBJECTIVE: To analyze the impact of CTC on colonoscopy demand DATA INPUTS: •	 Colonoscopy practice patterns data from 1998 to 2002 were used as the founda

(2003) colonoscopy practice. 

•	 The number of screening colonoscopies was observed to increase after July 20

presented reports as well as in the endoscopy unit experience at Massachusetts percentages of colonoscopies for average-risk screening were 14.2%, 3 20%, aand 33.5% for Massachusetts General Hospital). These trends were applied to tcurrent (2003) national estimates for the total number of screening colonoscopie

•	 Parameters: Population estimate; CTC and polyp characteristics: sensitivity, spe

CTC studies (positive findings), Number of patients (positive CTC findings); folloCTC after first study; surveillance colonoscopy for subsequent colonoscopies afdetected; 

•	 Because positivity thresholds are so pivotal to the analysis and no consensus ex

value, the authors chose to perform all analyses using both 6-mm and 10-mm vboundaries). 

ANALYSIS AND CALCULATIONS: •	 With a range between 40% (current or lower limit) and approximately 70% (mam

the authors estimated a CRC screening compliance of 55% (or a 15% increase) CTC. 

•	 Applying this estimate eliminated 45% (noncompliant, 100%-55%) of the eligible 

screening pool. 

•	 The authors reasoned that, within the 5 years following implementation of CTC (

period), all of the patients who underwent any of these screening modalities wouCRC screening; therefore, all of these patients were included in the screening pscreening colonoscopies are recommended every 10 years, the authors the aut(one half of the 17.5% of patients who had undergone colonoscopy within the paCRC screening in the following 5 years. The remaining cohort was divided by 5 of the first period of the model for reasons described previously, resulting in 7.21 

•	 In the 323 subjects studied, when given information about both procedures, 60.2

chose colonoscopy, and 14.2% were undecided. Based on these results, the baCTC penetrance was 67.3% (60.2% + one half of the undecided group) 

•	 The percentages of CTC examinations with positive findings using the base-cas

specificity, and prevalence values were 24.9% (6 mm) and 7.0% (10 mm). Thes
Evidence Table 3. KQ 4: Current and projected capacity to deliver colorectal cancer screening and surveillance (continued) 

STUDY:	 Authors: Hur et al.93 

Year: 2004 Trial name (if applicable): 

by the number of patients undergoing a CTC per year (4.85 million) yielded 1.21 million (10 mm) patients who would require a follow-up colonoscopy in the base 

•	 Patients who had negative findings on CTC examination were modeled to under

screening every 5 years, with colonoscopy reserved for those patients who had published polyp data from the Veterans Affairs Cooperative Study and definitiongroups from published polyp surveillance recommendations, the model assumeprevious adenomatous polyps would undergo surveillance colonoscopy every 3 years. 

RESULTS: KQ2 - What factors influence the use NA of colorectal cancer screening? KQ3 - Which strategies are effective NA in increasing the appropriate use of colorectal cancer screening and follow-up? 

C-338
 KQ4 - What are the current and projected capacities to deliver colorectal cancer screening and 

surveillance at the population level? 

Outcomes: Current volume: 6.47 million COLON 1.98 COLON for screening (29%) 

•	 If CTC used as primary modality for CRC screening, assuming 55% adherence 

penetrance, in the initial 5 year period after implementation of CTC, demand for by 1.78 million. This would be partially offset by 0.34 million follow up COLON ffindings (10 mm polyp) 

•	 The total additional colonoscopies for the second period (years 6–10) after imple

yield 1.67 million (6 mm) or .49 million (10 mm) procedures. These figures partireduction associated with implementation of CTC, resulting in a net reduction of mm) or 1.29 million (19.9%) (10 mm) of the current total number of colonoscopie

•	 To summarize the numerous sensitivity analyses performed, the model was sen

and polyp prevalence and also sensitive to the percentage of screening colonosimprovement in population compliance but only if the 6-mm polyp size cutoff wa

KQ5 - What are the effective NA approaches for monitoring the use and quality of colorectal cancer screening? QUALITY RATING: Fair 
Evidence Table 3. KQ 4: Current and projected capacity to deliver colorectal cancer screening and surveillance (continued) 

Quality Assessment for Modeling Studies Were data inputs valid? 

Yes No 

X 

Other 

Based 

datab

Was an appropriate search strategy used to find data inputs? X Were the calculations and statistical analyses adequate? X Were appropriate sensitivity analyses conducted (especially for any variables that were not based on X 

data from literature)? Other considerations: 

X 

This f

[These might include the following for various types of models: was the cost effectiveness analysis incorpconducted from the societal perspective? Was an appropriate comparison used (standard of care or next adjusmost effective alternative)? Were the appropriate health benefits, harms, and costs described and discoincluded?] perfor

effecteffort simple comp

Quality Rating (Good, Fair or Poor): Fair 

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Evidence Table 3. KQ 4: Current and projected capacity to deliver colorectal cancer screening and surveillance (continued) 

STUDY:	 Authors: Ladabaum et al.94 

Year: 2005 Trial name (if applicable): NA 

C-340
 

DESIGN: Study design: Modeling study 

Number of subjects: Time period covered: 

QUESTIONAIM/OBJECTIVE: To use a model and national census data to produce integrated, comprehensive estimates of 

screening on national clinical and economic outcomes and health services demand. The authdemand for colonoscopy in detail, including the relative contribution of surveillance. 

DATA INPUTS: 2000 Census data. 

Authors make reference to a previous publication for details about the model (model estimateand cost-effectiveness of CRC screening with established and emerging strategies). 

ANALYSIS AND CALCULATIONS: Decision analytic Markov model. The natural history model was calibrated to reproduce the a

autopsy of small and large adenomatous polyps and age and stage-specific CRC incidence raThe authors superimposed screening on the natural history model. The model was used to c

various screening proportions. The proportion of different screening tests was varied. Cost wvarious screening tests. Costs were determined in a prior publication in 2003 dollars, and wemedical component of the CPI. For each strategy, the model yielded the number of CRC cases by stage, deaths by cause, diand undiscounted average life-years and costs per person, and number and type of tests perfThe authors include results for each strategy’s average life-years and costs per person as wecompared with natural history (no screening) from the perspective of a third-party payer. The authors assumed a 75% screening uptake rate for the national projections. The authors assumed a steady state for the population size and age distribution, as representcensus data. The authors determined age-specific clinical model outputs per person and econadjusted these to reflect the fraction of persons still alive at a given age out of the original hyp

authors then multiplied these corrected, age-specific model outputs per person by the numbe

the US population based on year 2000 census data. Next, the authors corrected our estimatescreening uptake rate for each strategy. Adding the results for all ages under each strategy yinational estimates. 

RESULTS: KQ2 - What factors influence the use NA of colorectal cancer screening? 
Evidence Table 3. KQ 4: Current and projected capacity to deliver colorectal cancer screening and surveillance (continued) 

STUDY: Authors: Ladabaum et al.94 

Year: 2005 Trial name (if applicable): NA 

KQ3 - Which strategies are effective in increasing the appropriate use of colorectal cancer screening and follow-up? 

NA 

KQ4 - What are the current and projected capacities to deliver colorectal cancer screening and surveillance at the population level? 

Numbers of tests, including colonoscopies by indication and 

FOBT FS FS/FOBT Colonos

intervention (assuming 75% uptake) FS 10.0 million 6.9 million 

Colonoscopy 3.8 million 2.7 million 4.7 million 8.1 millio

CT colonography 

Table: National demand for health services under current and potential future scenarios 

Uptake 

increases 

75%; FOBT, 

Uptake Uptake FS/FOBT 

increases to increases to remain stab

Current 75%: all 75%: FOBT, FS, remainder 

screening established FS/FOBT screening w

uptake and strategies grow remain stable; COLO or V

Scenario rates by in same only COLO Pickhard

Description strategy proportion increases (ratio 1:1

C-341
 

Associated assumptions Total fraction of 40 75 75 75 

population screened (%) FOBT 

10 19 10 10 

 FS 8 15 8 8 

 FOBT/FS 8 15 8 8 COLO 

14 26 49 25 

VC-Pickhardt 

0 0 0 25 

Demand for health services (test #’s in 
Evidence Table 3. KQ 4: Current and projected capacity to deliver colorectal cancer screening and surveillance (continued) 

STUDY:	 Authors: Ladabaum et al.94 

Year: 2005 Trial name (if applicable): NA 

C-342
 

millions/year) FOBT 

7.1 13.3 7.1 7.1 

 FS 1.8 3.4 1.8 1.8 VC 

0 0 0 2.0 

COLO 

3.0 5.3 6.6 5.2 

Screening 1.9 3.5 4.7 3.3 Postpolypectomy 0.88 1.6 1.7 1.7 surveillance To diagnose 0.23 0.16 0.15 0.16 symptomatic CRC on surveillance after CRC treat 

Assuming current screening patterns and 40% uptake, 3.0 million total colonoscopies were remillion related to screening (primary screening with COLO or to follow up on positive screeninother strategies) and 0.88 million for postpolypectomy surveillance. With increased screening colonoscopy demand increased even under the scenario assuming substantial utilization of Vexamined, the number of postpolypectomy surveillance colonoscopies was similar (1.6-1.7 mnumber of colonoscopies for diagnosing symptomatic CRC or surveillance after CRC treatmeyear). In contrast, the number of colonoscopies related to screening varied from 2.7 to 4.7 milfunction of the rate of utilization of COLO. Focusing on colonoscopy, the authors estimated annual colonoscopy demand of 8.1 million wmillion with the other strategies. 

KQ5 - What are the effective NA approaches for monitoring the use and quality of colorectal cancer screening? QUALITY RATING: Good 
Evidence Table 3. KQ 4: Current and projected capacity to deliver colorectal cancer screening and surveillance (continued) 

Quality Assessment for Modeling Studies 

C-343
 

Were data inputs valid? 

Yes 

X 

No Other (CD, NR, N

Steady state pop

Other reports revSong K, Fendrick DNA testing comcolorectal cancer decision analysis126:1270–1279. Ladabaum U, SoColorectal neoplacolonoscopy: whwhat national impHepatol 2004; 2:5Ladabaum U, ChScheiman JM, CFendrick AM. Aspscreening for precolorectal canceranalysis. Ann Intern Med 2001; Ladabaum U, ScPotential effect ocyclooxygenase-the prevention of cost-effectivenes2003;114: 546–554. 

Was an appropriate search strategy used to find data inputs? X Were the calculations and statistical analyses adequate? X Were appropriate sensitivity analyses conducted (especially for any variables that were not NR based on data from literature)? Other considerations: 3rd party payer pe

[These might include the following for various types of models: was the cost effectiveness analysis conducted from the societal perspective? Was an appropriate comparison used Not clear time ho(standard of care or next most effective alternative)? Were the appropriate health benefits, projected, but no harms, and costs described and included?] Quality Rating (Good, Fair or Poor): Good 
C-344
 

Evidence Table 3. KQ 4: Current and projected capacity to deliver colorectal cancer screening and surveillance (continued) STUDY: Is there sufficient MDCT Authors: Pickhardt et al.95 capacity to provide colorectal cancer Year: 2008 screening with CT colonography for the Trial name (if applicable): NA 

U.S. population? DESIGN: Study design: modeling study 

Number of subjects NA Time period covered: # of existing scanners based on 2006 data, population data from U.S. 

projected over 10 year period. 

QUESTIONAIM/OBJECTIVE: The aim was to assess the ability of the available MDCT capacity in the United States to prov

with CTC. 

DATA INPUTS: Model construction: 

To address the first issue regarding the startup phase, the authors constructed a simple mathpredicting CTC demand by simulating progressive uptake of CTC on the compliant populationoutcome was the total number of CTC examinations needed per year, assuming a 10-year spframe for catching up with all the millions of unscreened 50- to 75-year-old individuals in the Uauthors assumed the routine screening interval for CTC would initially be set at 5 years, repeasecond half of the 10-year startup period were added to the new screenings in the startup phaTo deal with the second issue of steady-state demand, the authors used a previously validateestimate the total number of CTC examinations needed to be performed each year once the sreaches this steady state. The CTC totals from the two phases were then divided among all oavailable in the United States for the standard number of working days per year to establish thprocedures per day that each MDCT unit should perform to meet the simulated demand (exprCTC/MDCT/day). Inputs: The baseline values for the main parameters used in the startup and steady-state phase modapplied for the sensitivity analysis, are reported in Table 1. 2007 census data and literature is Population variables: U.S. adults 40 – 75 years old, all cause mortality per year (%), too frail for colonoscopy (%), p

CRC risk (%), overall screening compliance (%), CTC penetrance (%), compliance to repeat C

startup period (y), routine CTC screening interval (y), CT capacity variables: total CT units in Ufrom total (%), MDCT units performing CTC (%). The initial population consisted of the entire average-risk 40 to 75-year-old population availabThis population figure was adjusted to account for mortality from all causes and was further reconsidered to be too frail to undergo colonoscopy. The authors assumed that CTC implementacceptance for a noninvasive screening option would result in a gradual increase in the overaduring the 10-year startup period. For this reason, overall CRC screening compliance (by any grow in a linear fashion from 40% in year 1 to 60% at the end of the 10-year startup period. 

The authors assumed that only a certain fraction of the compliant screening population will fav
Evidence Table 3. KQ 4: Current and projected capacity to deliver colorectal cancer screening and surveillance (continued) 

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STUDY: Is there sufficient MDCT Authors: Pickhardt et al.95 capacity to provide colorectal cancer Year: 2008 screening with CT colonography for the Trial name (if applicable): NA 

U.S. population? 

available screening options, which progressively increased from an initial penetration of 10% 10 of the startup phase. Assuming third-party reimbursement for screening CTC, balanced by the need for appropriate in CTC-specific equipment (i.e., CTC software and carbon dioxide insufflator), the authors estonly gradually rise to 90% by the end of the 10-year startup period. Furthermore, the authors annual increase of 3.5% in the total number of CT scanners over the 10-year period and an in

percentage of MDCT scanners from the current 71% to 85% by year 10. 

ANALYSIS AND CALCULATIONS: To evaluate the number of CTC examinations performed in the steady-state phase of populat

used a Markov model on a hypothetical cohort of 100,000 average-risk subjects ranging from 

previously modeled in articles focusing on colonoscopic screening capacity. Briefly, the natural history of colorectal neoplasia was calibrated to reproduce the age- and seprevalence at autopsy and screening studies as well as the incidence and mortality rate of CRsuperimposed on the natural history model was CTC repeated every 5 years between 50 and For this analysis, the authors assumed that those found to have an adenoma > 5 mm required which prevented further CTC screening. All others were eligible for repeat screening CTC in 5 Although all endoscopic and radiologic CRC screening tests are advised to be repeated every 

compliance for repeated examinations over a lifetime period is largely unknown. Although somhave shown short-term compliance for repeated colonoscopy of 80%, the authors thought thayear CTC repetition over a lifetime to be a more realistic baseline assumption. To project the simulation on the entire U.S. population, the authors assumed a steady state for population sirepresented by the 2000 census data. 

RESULTS: KQ2 - What factors influence the use NA of colorectal cancer screening? KQ3 - Which strategies are effective NA in increasing the appropriate use of colorectal cancer screening and follow-up? KQ4 - What are the current and projected capacities to deliver Year Overall CTC No. to be Total CT MDCT MD

colorectal cancer screening and compliance penetrance screened units fraction (%) Un

surveillance at the population level? (%) (%) with CTC per

CT

1 40 10 295,750 10,110 71 718 2 42 16 506,664 10,500 73 1,43 45 22 738,665 10,890 74 2,24 47 29 991,754 11,280 76 3,1
Evidence Table 3. KQ 4: Current and projected capacity to deliver colorectal cancer screening and surveillance (continued) 

STUDY: Is there sufficient MDCT Authors: Pickhardt et al.95 capacity to provide colorectal cancer Year: 2008 screening with CT colonography for the Trial name (if applicable): NA 

U.S. population? 

5 49 35 1,265,929 11,670 77 4,0

6 52 41 1,709,066 12,060 79 5,1

7 54 47 2,130,872 12,450 80 6,3

8 56 53 2,584,309 12,840 82 7,5

9 58 60 3,069,376 13,230 83 8,8

10 60 67 3,586,073 13,620 85 10

Note—Overall compliance indicates total participation in screening, by any technique. CTC pe

percentage of compliant adults who favor CTC over other available screening options. MDCT percentage of all CT scanners that are multidetector and therefore CTC capable. MDCT units indicates the number (and fraction) of MDCT scanners actually performing CTC. Start up phase: “At the simulated compliance and eligibility rate, 37,227,541 U.S. adults would need to be scryear startup phase.” At sensitivity analysis, compliance to initial screening, CTC penetrance, MDCT capacity, the d

and the population size appeared to be key variables. Steady-state phase: Screening in the steady-state was simulated with 5-year repetition of CTC between the ages ocompliance and penetrance were set at 60% and 67%, corresponding to the values reached istartup period. Compliance for repeated CTC thereafter was set at 50%. The overall number oneeded to be performed per year in the steady-state period for the average-risk U.S populatioDividing this value by the estimated MDCT capacity at the end of the startup period corresponprocedures per MDCT per year and 1.2 CTC/MDCT/day. The authors conclude that available MDCT capacity in the US is large enough to satisfy the ppopulation screening with primary CTC evaluation, for both start up and steady state periods. 

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KQ5 - What are the effective NA approaches for monitoring the use and quality of colorectal cancer screening? QUALITY RATING: Fair 
Evidence Table 3. KQ 4: Current and projected capacity to deliver colorectal cancer screening and surveillance (continued) 

Quality Assessment for Modeling Studies Were data inputs valid? 

Yes X 

No Othe

Pick

LaghMoriof cowith colonot rlesio

109:

Was an appropriate search strategy used to find data inputs? X Were the calculations and statistical analyses adequate? X Stea

Very 

Were appropriate sensitivity analyses conducted (especially for any variables that were not based on data X 

from literature)? Other considerations: [These might include the following for various types of models: was the cost effectiveness analysis conducted from the societal perspective? Was an appropriate comparison used (standard of care or next most effective alternative)? Were the appropriate health benefits, harms, and costs described and included?] Quality Rating (Good, Fair or Poor): Fair 

C-347
 
C-348
 

Evidence Table 3. KQ 4: Current and projected capacity to deliver colorectal cancer screening and surveillance (continued) STUDY:	 Authors, ref ID: Robertson et al.96 

Year of publication: 2006 Dates of data collection: 1999 - 2001 Trial name: 

OBJECTIVE OR AIM: Examine trends in the utilization of flex sig, DCBE, and colonoscopy and trends in the cho

screening service providers within Tricare and Medicare from 1999 - 2001 

DESIGN: Setting: United States 

Study design: review of Tricare and Medicare claims data Duration (mean follow-up): Overall study size (N enrolled/N analyzed): (see tables below) 

RECRUITMENT: Two sources of data were used in this study: the Medicare Physician/Supplier Summary ((population-based, clinic-based, Health System's Management Analysis and Reporting Tool (M2). volunteer, other) INCLUSION CRITERIA: Only those Medicare beneficiaries over age 65 and in fee-for-service plans were analyzed

represents the military's commercial network (Tricare) claims, included beneficiaries age 5

EXCLUSION CRITERIA:	 NR POPULATION CHARACTERISTICS: 

NA 

Mean age & range (years): 

Sex (% female): Race: Other: Attrition/Drop-out (not available for endpoint measurement): Adherence:
 Contamination: Response Rates (e.g. for surveys): STATISTICAL ANALYSES: ASSESSMENT OF EXPOSURES AND POTENTIAL CONFOUNDERS: 

Since the data comprised the populations of Tricare and Medicare claims, descriptive rathwere used. The data were examined for changes in procedure volume for the three procechanges in colonoscopy provider volume. For the analysis of colonoscopy provider data, sprocedure volumes (i.e., colorectal surgeons, family practitioners, general practitioners, nuassistants, multi-specialty clinic) were combined into one provider category, “other”. 

OUTCOME ASSESSMENT: What type of provider performed screening test. 

Volume of screening tests performed. No distinction made between screening and diagnoThese were evaluated in 1999, 2000, and 2001 for both Medicare and Tricare. 
Evidence Table 3. KQ 4: Current and projected capacity to deliver colorectal cancer screening and surveillance (continued) STUDY:	 Authors, ref ID: Robertson et al.96 

Year of publication: 2006 Dates of data collection: 1999 - 2001 Trial name: 

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Results KQ2 - What factors influence the use of colorectal cancer screening? KQ3 - Which strategies are effective in increasing the appropriate use of colorectal cancer screening and follow-up? RESULTS: 

NA NA Colonoscopy by medical discipline, 1999 – 2001 

KQ4 - What are the current and projected capacities to deliver colorectal cancer screening and surveillance at the population level? 

Disci pline 

1999 2000 

TC MC TC MC 

 N % of N % N % of N % of 

total of total total 

total 

GI 18,208 59 GS 2,706 9 IM 3,197 10 Other 6,576 21 Total 30,687 100 Procedure volume by year 1999-2001 B.E. 6,457 12 Colo 30,687 58 F.S. 15,668 30 Total 52,812 100 

1,047,044 

209,195 187,954 

146,662 

1,590,855 

394,949 

1,590,855 

690,056 

2,675,860 

66 

13 12 

9 

100 

15 

59 

26 

100 

26,455 

3,974 3,939 

2,216 36,584 

5,572 

36,584 

15,052 

57,208 

72 

11 11 

6 

100 

10 

64 

26 

100 

1,202,192 

243,571 201,079 173,378 1,820,220 340,277 1,820,220 

603,420 

2,763,917 

66 

13 11 

10 

100 

12 

66 

22 

100 

TC = Tricare MC = Medicare GI = Gastroenterologist GS = general surgeon IM = Internal Medicine B.E. = barium enema Colo = colonoscopy F.S. = flexible sigmoidoscopy Summary: 
Evidence Table 3. KQ 4: Current and projected capacity to deliver colorectal cancer screening and surveillance (continued) 

STUDY:	 Authors, ref ID: Robertson et al.96 

Year of publication: 2006 Dates of data collection: 1999 - 2001 Trial name: 

C-350
 

“The total volume of procedures increased 5% and 14%, respectively, in Tricare and MedMedicare, respectively, saw 32% and 33% reductions in barium enemas and 28% and 41sigmoidoscopies. Colonoscopies increased by 45% and 34% in Tricare and Medicare, resGastroenterologists provided the majority of colonoscopies for both groups each year.” 

KQ5 - What are the effective approaches NA for monitoring the use and quality of colorectal cancer screening? QUALITY RATING: Quality Assessment-Internal Validity for Observational Studies 

Yes No O

Were the groups similar at baseline regarding the most important prognostic indicators? N

Were the drop-out or response rates acceptable (≤ 20%)? [If between 20% and 60%, check other and explain.] N

Were the differential drop-out or response rates acceptable (≤ 15%)?	 N

Were intervention/exposure measures valid, reliable, and equally applied? X 

Were the outcome assessors blinded to the intervention or exposure status of subjects? N

Were outcome measures valid, reliable, and equally applied? X N

sp

Does the analysis control for baseline differences? N

Were important potential confounding and modifying variables taken into account in the design and analysis N

(e.g., through matching, stratification, or statistical adjustment)? Were the statistical methods used to assess the abstracted outcomes appropriate? X 

Quality Rating (Good, Fair, or Poor): Fair 
Evidence Table 3. KQ 4: Current and projected capacity to deliver colorectal cancer screening and surveillance (continued) 

C-351
 

STUDY: “Is there endoscopic capacity to Authors, ref ID: Seeff et al.97 provide colorectal cancer screening to the Year of publication: 2004 unscreened population in the United Dates of data collection: 2000 & 2001 States?” Trial name: OBJECTIVE OR AIM: The authors designed a forecasting model to (1) estimate the number of average-risk peo

who have not been screened for colorectal cancer, (2) describe the sociodemographic chapopulation, and (3) estimate the annual number of procedures required to provide screeniexaminations for this population. This report compares available capacity calculated in a companion publication {#3269) wineeded for the currently unscreened population, assuming that all or one half of the availacolorectal cancer screening. The authors focused on the average-risk population in this anexists about when to begin and how to screen the average-risk population for colorectal c

DESIGN: Setting: United States 

Study design: Modeling study Duration (mean follow-up): NA Overall study size (N enrolled/N analyzed): NA 

Data sources: To estimate the size of the US population currently unscreened for colorectal cancer, the 

size of the total US population aged 50 years or older in 2001, stratified by sex, race, ethnage, using US Census Bureau 2000 Public Use Microdata Sample data. Insurance status income, region, and age was estimated using data from the March Current Population SuThe authors then identified and removed persons at increased risk for colorectal cancer, ipersonal or family history of colorectal cancer and those with inflammatory bowel diseaseestimated the need for average-risk persons only. Colorectal cancer prevalence rates by asex were obtained from the Surveillance, Epidemiology and End Results program. The sizfamily history of colorectal cancer was obtained from the 2000 NHIS. Persons were considhistory of colorectal cancer if they had a parent, sibling, or child who had been diagnosed any age. The number of individuals with inflammatory bowel disease was obtained from thDiabetes and Digestive and Kidney Diseases. Although the prevalence of inflammatory borace/ ethnicity, and sex, the authors assumed an equal prevalence across age, race/ethnia mortality rate for inflammatory bowel disease equal to that of the general population. Ap

persons (1.3% of the population aged 50 years or older) with a personal history of colorecpersons (6.8% of the population aged 50 years or older) with a family history of colorectal persons (.2% of the population aged 50 years or older) with inflammatory bowel disease, risk for colorectal cancer, were excluded from the total population in need of screening. 

STATISTICAL ANALYSES: The authors used a 2-step modeling method to determine the size of the screened popula

used data from the 2000 NHIS15 to construct a multivariate multinomial logistic regressiorelationship between sociodemographic characteristics (e.g., age, sex, race, income levelregion of the United States) and the probability that an individual has been screened for cto current guidelines: FOBT in the past year, endoscopy (flexible sigmoidoscopy, colonoscpast 10 years, both FOBT in the past year and endoscopy in the past 10 years, or none o
Evidence Table 3. KQ 4: Current and projected capacity to deliver colorectal cancer screening and surveillance (continued) 

STUDY: “Is there endoscopic capacity to Authors, ref ID: Seeff et al.97 provide colorectal cancer screening to the Year of publication: 2004 unscreened population in the United Dates of data collection: 2000 & 2001 States?” Trial name: 

C-352
 

NHIS respondents were asked about their use of any lower endoscopic procedure (sigmoproctoscopy) but were only asked to identify which of the 3 endoscopic procedures they hThe authors therefore measured the use of all endoscopies combined and used10 years a

according to recommended guidelines to fully capture colonoscopy use. NHIS respondenttheir use of double-contrast barium enema (DCBE). Stata 6.0 was used to account for the survey design and to calculate 95% confidence intervals. In step 2, the coefficients from the logistic regression model described previously were usproportion of persons who have been screened. These proportions were applied to the avaged 50 years or older to generate counts of the population already screened for colorectFinally, the authors subtracted the number of individuals who have already been screened population to produce an estimate of the number of average-risk persons in the US popula

colorectal cancer screening. To determine the number of procedures needed to screen this unscreened average-risk pmodeled 5 program options under which screening could occur. The first program assumeoccur with a combination of screening tests in proportions consistent with the current test NHIS. To determine the number and type of tests needed in this scenario, the coefficients 

analysis were applied to the unscreened average-risk population to predict the numbers o(FOBT only, sigmoidoscopy only, sigmoidoscopy plus FOBT, and colonoscopy) based on characteristics of the unscreened average-risk population. To determine endoscopies by tthat the most recent test reported in the NHIS was the only test performed. The other 4 prbecause they each represent screening options recommended by national guidelines. Thethe unscreened population would be screened with (1) annual FOBT with diagnostic colon(2) FOBT plus sigmoidoscopy, (3) sigmoidoscopy with diagnostic colonoscopy for positive For the program using FOBT and sigmoidoscopy, the authors assumed that all persons wFOBT, with positive FOBTs followed by a diagnostic colonoscopy. Persons with a negativscreening sigmoidoscopy with positive sigmoidoscopies followed by a diagnostic colonoscFor any of the proposed screening programs, positive FOBTs and flexible sigmoidoscopiediagnostic colonoscopy. To estimate the number of diagnostic colonoscopies that would bthe unscreened population, the authors applied a positivity rate of 2.5% for unrehydrated sigmoidoscopy. For individuals undergoing both FOBT and sigmoidoscopy during 1 year, applied, which assumes that FOBT is performed annually but only one fifth of the people reach year and one half of the positive cases identified through sigmoidoscopy are not ide

RESULTS: KQ2 - What factors influence the use of NA colorectal cancer screening? KQ3 - Which strategies are effective in NA increasing the appropriate use of 
Evidence Table 3. KQ 4: Current and projected capacity to deliver colorectal cancer screening and surveillance (continued) 

STUDY: “Is there endoscopic capacity to Authors, ref ID: Seeff et al.97 provide colorectal cancer screening to the Year of publication: 2004 unscreened population in the United Dates of data collection: 2000 & 2001 States?” Trial name: colorectal cancer screening and followup? KQ4 - What are the current and projected capacities to deliver colorectal cancer screening and surveillance at the population level? 

Assuming all available sigmoidoscopic capacity is used for colorectal cancer screening, thscreen the unscreened population with a program based on current screening patterns if tmore years, but 6 years would be required to screen the unscreened population using 100plus sigmoidoscopy. If only one half of the available capacity were used for screening, it wscreen the unscreened population based on current screening patterns and 10 years usinor FOBT plus sigmoidoscopy. This would not take into account repeat screening tests neeor tests needed to keep the screened population current with their screening tests. 

C-353
 

Comparing the need for colonoscopy with available capacity, if all available capacity were would take 5 years to screen the unscreened population using 100% screening colonoscoprogram based on current screening patterns. Two of the programs that have available corequire sigmoidoscopy as well; sigmoidoscopy is in a shortage until the sixth year. For a p
Evidence Table 3. KQ 4: Current and projected capacity to deliver colorectal cancer screening and surveillance (continued) 

STUDY: “Is there endoscopic capacity to Authors, ref ID: Seeff et al.97 provide colorectal cancer screening to the Year of publication: 2004 unscreened population in the United Dates of data collection: 2000 & 2001 States?” Trial name: 

FOBTs with diagnostic colonoscopies for positive tests, there would be enough capacity to follow-up colonoscopies within 1 year. If only one half of the available colonoscopy capacit would take 4 years to screen the unscreened population using a program based on curr10 years using 100% colonoscopy. For a program designed to screen only an uninsured, low-income population between 50 is enough sigmoidoscopic and colonoscopic capacity to screen the unscreened population the proposed programs. 

C-354 

KQ5 - What are the effective approaches NA for monitoring the use and quality of colorectal cancer screening? QUALITY RATING: Good Quality Assessment for modeling studies: 

Yes No 
Evidence Table 3. KQ 4: Current and projected capacity to deliver colorectal cancer screening and surveillance (continued) 

Were data inputs valid? X Other considerations: [These might include the following for various types of models: was the cost effectiveness analysis conducted from the societal perspective? Was an appropriate comparison used (standard of care or next most effective alternative)? Were the 

appropriate health benefits, harms, and costs described and included?] 

Was an appropriate search strategy used to find data inputs? X Were the calculations and statistical analyses adequate? X Were appropriate sensitivity analyses conducted (especially for any variables that were not based on data from literature)? X Quality Rating (Good, Fair or Poor): Good
 

C-355
 
C-356
 

Evidence Table 3. KQ 4: Current and projected capacity to deliver colorectal cancer screening and surveillance (continued) STUDY: “How many endoscopies are Authors, ref ID: Seeff et al.98 performed for colorectal cancer screening? Year of publication: 2004 

Results from CDC’s survey of endoscopic Dates of data collection: April to September 2002 capacity”	 Trial name: Data from Survey of Endoscopic Capacity (SECAP) used for this study 

OBJECTIVE OR AIM: The purpose of this survey was to provide an estimate of the current capacity for endosco

examinations in the United States. 

DESIGN: Setting: United States, medical practices that were known to have purchased or leased lo

between 1996 and 2000 were surveyed. Study design: Telephone & mailed survey Duration (mean follow-up): Overall study size (N enrolled/N analyzed): Surveys were mailed to 1809 practices and surveys were returned. Of the returned surveys, 78 were ineligible; 1268 surveys were an

Sample size: Sample of 1809 practices 

Describe intervention: The sampling frame included all US medical facilities known to have purchased or leased 

(sigmoidoscopy and colonoscopy) equipment between January 1, 1996, and December 3obtained lists of these customers from the 4 leading US endoscopic equipment manufactuAmerica, Pentax Precision Instruments Inc, and Welch-Allyn. The authors also obtained a and multispecialty ambulatory endoscopy/surgery centers (AECs) in the United States frocompany that owns and manages AECs. The 4 manufacturer lists were merged and sorted by ZIP code, city, and purchaser name. removed to create a sampling frame that represented a single record for each practice. ThZIP code, city, and purchaser name and maintained in a separate file to allow for oversamlocations were classified using a ZIP code version of the rural-urban commuting area codrural-urban dichotomy, rural-urban commuting area codes 1 (urban core census tract) throtied to urban core) were considered urban, and codes 4 (large town census tract) through census tract) were considered rural. Stratified sample US census region and by urban/rural location. AECs and rural practices 

RECRUITMENT: Sample of practices known to provide colonoscopy, as described above. (population-based, clinic-based, $40 reimbursement for survey response volunteer, other) INCLUSION CRITERIA:	 US medical facilities know to have purchased or leased lower endoscopic equipment duriEXCLUSION CRITERIA:	 Not currently performing lower GI procedures in adults, or address/phone number that couPOPULATION CHARACTERISTICS:	 Survey respondents identified themselves as physicians (81.6%), nurses 

(5.7%), and “other” (12.7%), which included administrators. 

Mean age & range (years): Sex (% female): Responding physicians identified their practice specialties as Race: gastroenterology (49.0%), internal medicine (21.5%), surgery (16.9%), and 

family or general practice (12.0%). 

Other: Response Rates (e.g. for surveys): Surveys were mailed to 1809 practices and 1346 (74.4%) completed surveys were returne

78 were ineligible; 1268 surveys were analyzed. 
Evidence Table 3. KQ 4: Current and projected capacity to deliver colorectal cancer screening and surveillance (continued) 

C-357
 

STUDY: “How many endoscopies are Authors, ref ID: Seeff et al.98 performed for colorectal cancer screening? Year of publication: 2004 

Results from CDC’s survey of endoscopic Dates of data collection: April to September 2002 capacity”	 Trial name: Data from Survey of Endoscopic Capacity (SECAP) used for this study 

STATISTICAL ANALYSES: Once data collection was completed, the eligibility rate for the sampled facilities was appli

produce a total number of possible practices in each stratum. Sampling weights were comnumber of practices in each stratum by the total number of completed surveys in those stradjusted for differences in the probability of being selected and response rates across celmultiplied each survey response by the corresponding survey weight to obtain an estimate facilities in the United States that perform flexible sigmoidoscopy and colonoscopy, the totthat are currently being performed, and the maximum number of procedures that could be resources. These estimates are generalizable to the population of all US health care pracgastrointestinal flexible endoscopic equipment for the detection of colorectal cancer in aduweekly estimates were then multiplied by the number of workweeks per year to obtain natauthors assumed a 46-week working year across all practice specialties and facility types professional travel, and nonprocedural time. The survey data were analyzed and 95% confidence intervals (CIs) were calculated using sampling design effects. For the estimation of endoscopic capacity, 2 survey questions wethe number of procedures currently performed and the maximum number of procedures thThese data items were imputed when missing (40 surveys were missing current endoscopwere missing potential endoscopic volume data) using a variation of the hot-deck methodcurrent volume data, a current volume estimate was randomly selected from all surveys westimates and used as a replacement for the missing current volume value. For surveys wmaximum volume data, a ratio of current volume to potential volume was randomly selectwith known current and potential volume estimates, multiplied by the current volume estimreplacement for the missing potential volume value. 

ASSESSMENT OF EXPOSURES AND NA POTENTIAL CONFOUNDERS: OUTCOME ASSESSMENT: Respondents were asked to Identify their practice as private practice, an AEC, or a hospit

inconsistent, making it difficult to classify facilities by facility type. For this analysis, facilitiaccording to the practice specialty based on types of physicians that perform the majority 

procedures were performed by GI, the facility is classified as a GI practice. Same for primIf no dominant physician specialty, the facility was classified as a mixed practice. Survey respondents were asked to estimate the weekly number of flexible sigmoidoscopiepractice (“During a typical week, how many flexible sigmoidoscopies are performed by all physician endoscopists in this practice site?”) and the weekly potential maximum number (“If the demand for colorectal cancer screening were to increase substantially, what is the flexible sigmoidoscopies that could be provided at this practice site per week with no otheresources?”). The same questions were asked about colonoscopy volume. Available capaby taking the difference between the current and the potential volume. 

RESULTS: KQ2 - What factors influence the use of NA colorectal cancer screening? KQ3 - Which strategies are effective in NA 
Evidence Table 3. KQ 4: Current and projected capacity to deliver colorectal cancer screening and surveillance (continued) 

STUDY: “How many endoscopies are Authors, ref ID: Seeff et al.98 performed for colorectal cancer screening? Year of publication: 2004 Results from CDC’s survey of endoscopic Dates of data collection: April to September 2002 capacity” Trial name: Data from Survey of Endoscopic Capacity (SECAP) used for this study increasing the appropriate use of colorectal cancer screening and followup? 

C-358
 

KQ4 - What are the current and projected capacities to deliver colorectal cancer screening and surveillance at the population level? 

Number and Specialty of US Practice Sites that perform flexible sigmoidoscopy and 2002 

Procedure Total (95% CI) Gastroenterology Primary care Surgical 

practices (95% CI) practices (95% practices 

CI) CI) 

Any lower endoscop y 

Total 8207 3800 (3582 – 4017) 1644 (1456 – 988 (838 

1832) 1138) 

N.E. 1611 (1604 – 1618) 970 (874 – 1066) 195 (128 – 262) 154 (95 – 

 South 2890 (2878 – 2901) 1417 (1287 – 1547) 542 (435 – 649) 429 (332  M.W. 2082 (2074 – 2090) 678 (574 – 782) 463 (363 – 563) 257 (180  West 1624 (1615 – 1634) 734 (633 – 835) 444 (345 – 543) 149 (87 – 

Flex Sig 

Total 6732 (6557 – 6907) 2851 (2644 – 3058) 1563 (1397 – 708 (577 

1769) 

N.E. 1363 (1292 – 1434) 756 (658 – 854) 195 (128 – 262) 147 (89 – 

South 2292 (2184 – 2400) 1046 (922 – 1170) 513 (409 – 617) 329 (242 

 M.W. 1752 (1667 – 1837) 508 (414 – 602) 456 (357 – 555) 141 (82 –  West 1325 (1243 – 1407) 541 (445 – 637) 420 (323 – 517) 91 (40 – 

Colonosc opy 

Total 6214 (6016 – 6412) 3373 (3158 – 3588) 300 (211 – 389) 822 (684 

N.E. 1217 (1130 – 1304) 825 (727 – 923) 13 (0 – 32) 94 (47 – 

 South 2230 (2118 – 2342) 1266 (1138 – 1394) 128 (71 – 185) 360 (270 

 M.W. 1602 (1505 – 1699) 596 (495 – 697) 109 (56 – 162) 228 (156  West 1165 (1065 – 1265) 686 (586 – 786) 49 (12 – 86) 140 (80 – 

Number of flex sigs and colonoscopies performed by week by practices that own oequipment, per practice, by practice specialty, 2002 

Procedure GI practices (95% Primary Care Surgical practices 

CI) practices (95% CI) (95% CI) 

Flex sig % of practices that 76.0 (72.5 – 79.5) 96.3 (93.8 – 98.8) 72.7 (65.2 – 80.2) 

perform 
Evidence Table 3. KQ 4: Current and projected capacity to deliver colorectal cancer screening and surveillance (continued) 

C-359
 

STUDY: “How many endoscopies are Authors, ref ID: Seeff et al.98 performed for colorectal cancer screening? Year of publication: 2004 Results from CDC’s survey of endoscopic Dates of data collection: April to September 2002 capacity” Trial name: Data from Survey of Endoscopic Capacity (SECAP) used for this study 

 Current # (mean) 9.0 (7.0 – 11.0) 5.0 (4.1 – 5.9) 14.4 (8.9 – 19.9) 

Performed for 38.0 (34.5 – 41.5) 78.6 (75.1 – 82.1) 43.9 (36.4 – 51.4) screening (%) Potential 37.7 (31.0 – 44.4) 14.3 (12.6 – 16) 34.6 (26.2 – 43) 

maximum # (mean) Colonoscopy % of practices that 88.8 (86.2 – 91.4) 18.6 (13.6 – 23.6) 83.2 (77.1 – 89.3) perform  Current # (mean) 65.5 (52.8 – 78.2) 8.3 (6.5 – 10.1) 15.8 (13.1 – 18.5) Performed for 45.6 (43.5 – 47.7) 52.3 (44.6 – 60) 48.3 (42.5 – 54.1) 

screening (%) Potential 100.0 (86.3 – 113.7) 19.7 (15.7 – 23.7) 32.9 (26.9 – 38.9) 

maximum # (mean) 

Percentage of all FS and Colonoscopies performed by physician specialty, 2002Spe

Flex sig % (95% CI) Colonscopy % ((%% CI) GI 43.7 (37.2-50.2) 82.5 (80.PCP 24.9 (20.3-29.5) 2.0 (1.4Surgeon 20.5 (14.2-26.8) 10.8 (9.lResident with supervising MD 1.4 (0.2-2.6) Fellow with supervising MD 2.5 (1.3-3.7) 0.2 (0.1-0.3

4.3 (2.1-6.

Non MD 6.1 (2.1-10.1) 0.0 (0-0.1Other 0.7 (0-1.9) 0.1 (0-0Current Volume, potential volume and available capacity for annual a flex sigs and c(in millions), 2002 

Current volume (95% CI) Potential volume (95% CI) 

Flex sig All regions 2.8 (2.4 – 3.1) 9.5 (8.4 – 10.5) 

N.E. 0.7 (0.6 – 0.9) 2.5 (1.7 – 3.2) 

M.W. 0.7 (0.6 – 0.9) 2.2 (1.8 – 2.7) 

South 0.8 (0.6 – 0.9) 3.2 (2.8 – 3.6) 

West 0.6 (0.4 – 0.7) 1.6 (1.3 – 1.9) 

Colonoscopy All regions 14.2 (12.1 – 16.4) 22.4 (20.1 – 24.8) N.E. 4.2 (2.2 – 6.1) 5.9 (3.9 – 7.8) 

M.W. 3.1 (2.6 – 3.7) 5.1 (4.4 – 5.9) 

South 4.8 (4.3 – 5.4) 8.0 (7.1 – 8.9) 

West 2.1 (1.8 - 2.5) 3.5 (2.9 – 4.0) 

a Assuming 46 workweeks / year 
C-360
 

Evidence Table 3. KQ 4: Current and projected capacity to deliver colorectal cancer screening and surveillance (continued) STUDY: “How many endoscopies are Authors, ref ID: Seeff et al.98 performed for colorectal cancer screening? Year of publication: 2004 Results from CDC’s survey of endoscopic Dates of data collection: April to September 2002 capacity” Trial name: Data from Survey of Endoscopic Capacity (SECAP) used for this study b Difference between current and potential volumes 

A total of 8207 practice sites across the county performed flexible sigmoidscopy or colonoand follow up. Approximately 2.8 million flexible sigmoidoscopies and 14.2 million colonoscopies were esperformed in 2002, approximately one half of them for screening. Across all practice spec

64.7% of colonoscopies were performed for screening.
 Survey respondents reported that they could increase their flexible sigmoidoscopy volume million procedures annually, an increase of 29%, and could increase their colonoscopy vo20.1–24.8) million annually, an increase of 63%. Additional available capacity for FS and colonoscopy greatest in the South in terms of abspercentage of potential volume that is additional available capacity; lowest additional avaiabsolute number is the West; in terms of percentage it is the Northeast.
 

KQ5 - What are the effective approaches for monitoring the use and quality of colorectal cancer screening? QUALITY RATING: 

NA 

Quality Assessment-Internal Validity for Observational Studies 

Yes No Oth

Were the groups similar at baseline regarding the most important prognostic indicators? NA 

Were the drop-out or response rates acceptable (≤ 20%)? [If between 20% and 60%, check other and X 

explain.] Were the differential drop-out or response rates acceptable (≤ 15%)? Not 

Were intervention/exposure measures valid, reliable, and equally applied? NA Were the outcome assessors blinded to the intervention or exposure status of subjects? NA 

Were outcome measures valid, reliable, and equally applied? X Does the analysis control for baseline differences? NA Were important potential confounding and modifying variables taken into account in the design and NA 

analysis (e.g., through matching, stratification, or statistical adjustment)? Were the statistical methods used to assess the abstracted outcomes appropriate? X 

Quality Rating (Good, Fair, or Poor): Good 
C-361
 

Evidence Table 3. KQ 4: Current and projected capacity to deliver colorectal cancer screening and surveillance (continued) STUDY:	 Authors: Vijan et al.99 

Year: 2004 Trial name (if applicable): NA 

DESIGN: Study design: Use of previous Markov model 

Number of subjects: The authors used the current population of the United States, ages 50–Time period covered: October 2002 to October 2003 

QUESTIONAIM/OBJECTIVE: To quantify the demand for colonoscopy with different screening tests, and to estimate the ab

health care system to meet demand. 

DATA INPUTS: •	 For this analysis, the authors used the decision model to estimate the number o

flexible sigmoidoscopies undergone using several screening strategies: flexible with fecal occult-blood testing (FS/FOBT), a single colonoscopy at ages 50, 60, colonoscopy undergone at ages 50 and 60, or colonoscopy every 10 years. Poscreening FS/FOBT resulted in performance of colonoscopy. Patients in whom hpolyps were diagnosed (polyps 1 cm or greater, three or more polyps, or polyps underwent an initial surveillance colonoscopy at 3-years; if this endoscopy was surveillance was carried out at 5-year intervals. 

•	 The average rate of colonoscopy performance was then extrapolated to all USA 

authors then increased this number by 33%, based on the assumption that somcolonoscopies that are performed by providers other than gastroenterologists 

ANALYSIS AND CALCULATIONS: •	 The cohort was divided into 5 year clusters and the model was run to assess the 

colonoscopies and flexible sigmoidoscopies that would be necessary for each othe remaining lifetime of the cohort. 

•	 The authors ran these calculations using two main scenarios. In the first, the aut

adherence level of 70%; i.e. 70% in the age-range were eligible for and followed initial screening. In the second, as an upper bound of demand estimates, the aupatients were eligible, but that the total proportion of eligible and willing patients measure for comorbidity). 

•	 The authors used the CORI data to calculate the average number of colonoscop

by USA gastroenterologists from October 2002 through September 2003. 

•	 The average rate of colonoscopy performance was then extrapolated to all USA 

(11,044). The authors then increased this number by 33%, based on the assumscreening-related colonoscopies that are performed by providers other than gas

•	 The authors then calculated the incremental number of colonoscopies that woul

various screening scenarios by subtracting the number of screening-related coloat present from the total number of colonoscopies predicted by the decision mod

•	 The authors also conducted sensitivity analyses varying the proportion of endos

specialties other than gastroenterology. 

•	 In the base case, approximately 46% of colonoscopies are related to screening 

average risk individuals; the authors ranged this from 46 (e.g. no shift) to 66% (a analyses. 
Evidence Table 3. KQ 4: Current and projected capacity to deliver colorectal cancer screening and surveillance (continued) 

STUDY:	 Authors: Vijan et al.99 

Year: 2004 Trial name (if applicable): NA 

RESULTS: 

C-362
 

KQ2 - What factors influence the use NA of colorectal cancer screening? KQ3 - Which strategies are effective NA in increasing the appropriate use of colorectal cancer screening and follow-up? KQ4 - What are the current and Outcomes: projected capacities to deliver • Current volume: colorectal cancer screening and Estimated 1.27 million screening colonoscopies per year conducted by gastroenterosurveillance at the population level? screening colonoscopies per year by all types of providers 

Average of 21 colonoscopies (range 0-102) per month 

Even under the most favorable sensitivity analysis assumptions, a single colonoscopic screquires the fewest number of colonoscopies, would require between 1360 and 4160 mo•	 The more effective but also more resource intensive strategies would require a three 

from the current number (11 044) of gastroenterologists in order to meet demand. HFOBT/FS-based strategy would require a substantial increase in the number of gastrfrom a 30 to 110% increase, depending on assumptions about eligibility and the numthat could be performed. 

•	 If a group of dedicated endoscopists were trained a much smaller number of new en

required to meet the projected demand. For example, if colonoscopy every 10 years 

strategy, and a dedicated endoscopist can perform 200 colonoscopies per month (ab

between 2100 and 2600 endoscopists could theoretically meet demand. 

70% of age-eligible subjects 

Incr. # of screen-related colonoscopies 

FOBT/FS 1.20 COLON every 10 years 5.03 

100% of age-eligible subjects 

Incr. # of screen-related colonoscopies 

FOBT/FS 2.39 1 COLON every 10 years 6.27 KQ5 - What are the effective NA 

approaches for monitoring the use and quality of colorectal cancer 
Evidence Table 3. KQ 4: Current and projected capacity to deliver colorectal cancer screening and surveillance (continued) 

STUDY:	 Authors: Vijan et al.99 

Year: 2004 Trial name (if applicable): NA 

screening? QUALITY RATING: Fair for capacity estimates; Good for demand estimates Quality Assessment for Modeling Studies 

Yes No 

Were data inputs valid? X 

Was an appropriate search strategy used to find data inputs? X Were the calculations and statistical analyses adequate? X Were appropriate sensitivity analyses conducted (especially for any variables that were not based on data from X literature)? Other considerations: [These might include the following for various types of models: was the cost effectiveness analysis conducted from the societal perspective? Was an appropriate comparison used (standard of care or next most effective alternative)? Were the appropriate health benefits, harms, and costs described and included?] Quality Rating (Good, Fair or Poor): Fair for capacity estimates; Good for demand estimates 

C-363
 
Evidence Table 4. KQ5: Effective approaches for monitoring use and quality of colorectal cancer screening 

STUDY: The use of screening Authors, ref ID: El-Serag, Peterson, Hampel, Richardson, Cooper 100 colonoscopy for patients cared for by the Year of publication: 2006 Department of Veterans Affairs Dates of data collection: 1998 - 2003 

Trial name: NA 

OBJECTIVE OR AIM: To investigate whether colonoscopy use increased disproportionately in the VA system an

DCBE, and FOBT use between October 1, 1998, and September 30, 2003. 

DESIGN: Setting: United States, VA medical centers 

Study design: cross-sectional Duration (mean followup): NA Overall study size (N enrolled/N analyzed): 

Sample size: NA Describe intervention: NA RECRUITMENT: Population based- from VA databases 

(population-based, clinic-based, volunteer, other) INCLUSION CRITERIA: Procedures for VA users aged 49 to 75 years.
 

C-364 EXCLUSION CRITERIA: NR 

POPULATION CHARACTERISTICS: Mean age & range (years): Colonoscopy: 62.3 (7.6) years FOBT: 63.9 (7.8) DCBE: 62.6 (7.8) FS: 61/8 (7.7) Sex (% female): Race: Other: 

Feature Screening c-scope FOBT DCBE (n=78,830) 

(n=178,853) (n=1,635,364) 

Race White 105,746 (59.1) 815,582 (49.9) 45,894 (58.2) 

Black 17,934 (10.0) 133,822 (8.2) 10,458 (13.3) 

Other 55,173 (30.8) 685,960 (41.9) 22,478 (28.5) 

Sex Male 174,356 (97.5( 1,583,775 (96.8) 76,427 (97.0) 

 Female 4,497 (2.5) 51,589 (3.2) 2,403 (3.0) 

The mean (SD) age of those undergoing screening colonoscopy was 62.3 (7.6) years; FO

DCBE, 62.6 (7.8) years; and FS, 61.8 (7.7) years. 

Attrition/Drop-out (not available for NR 

endpoint measurement): Adherence:
 Contamination: Response Rates (e.g. for surveys): STATISTICAL ANALYSES: The frequencies and proportions of the 4 types of CRC screening procedures, and of uniq

these procedures, were calculated for each fiscal year. The temporal changes and potent
Evidence Table 4. KQ5: Effective approaches for monitoring use and quality of colorectal cancer screening (continued) 

STUDY: The use of screening Authors, ref ID: El-Serag, Peterson, Hampel, Richardson, Cooper 100 colonoscopy for patients cared for by the Year of publication: 2006 Department of Veterans Affairs Dates of data collection: 1998 - 2003 

Trial name: NA 

C-365 

and race) of screening colonoscopy (vs other CRC screening tests) were examined in unalogistic regression analyses. Similar calculations were performed for screening colonoscopy (vs other colonoscopy). St

these proportions were not performed because of overlapping groups. 

ASSESSMENT OF EXPOSURES AND POTENTIAL CONFOUNDERS: 

The authors used the predictive values to perform a sensitivity analysis of the calculated pcolonoscopy. National inpatient and outpatient VA databases used to assess potential confounders/cov

OUTCOME ASSESSMENT: National inpatient and outpatient VA databases were searched for codes indicative of colo

DCBE recorded during fiscal years 1998 to 2003. The authors also used the VA Patient Tcontains hospital discharge records and up to 10 diagnostic codes, 5 operating room procnonoperating room procedures coded according to the International Classification of Dise

Clinical Modification. The indications for CRC screening tests were classified as screening, diagnosis, or survepredefined Algorithm. All FOBT procedures were designated as screening procedures. FleDCBEwere considered diagnostic in the presence of specific conditions recorded within th

the procedure. They were considered to be surveillance procedures in the presence of a sconditions (coded as 17-28). The remaining procedures were considered to be screening was considered for CRC screening in the absence of conditions associated with diagnostiand if no colonoscopy had been performed within the past 4 years. 

RESULTS: 

Because of concerns of the accuracy of diagnosis and procedure codes for specifying proauthors also conducted a medical record review study in a subset of colonoscopic procedstudy cohort to validate and refine the algorithm that was used. A review of procedure, panotes was performed by 2 boardcertified gastroenterologist investigators who were blinde

based on the VA administrative data sets. They categorized indications for procedures as diagnostic. A total of 303 medical records of unique patients with colonoscopy performed at the MichaCenter, between October 6, 1999, and September 30, 2003, were identified at random usalgorithm, and reviewed from the national databases (ie, a subset from the main study cothe 2 reviewers was achieved in 92.0% of cases, and differences were resolved by discusof the database algorithm for identifying screening colonoscopy (compared with the medicstandard) were calculated. 

KQ2 - What factors influence the use of colorectal cancer screening? 

NA 
Evidence Table 4. KQ5: Effective approaches for monitoring use and quality of colorectal cancer screening (continued) 

STUDY: The use of screening Authors, ref ID: El-Serag, Peterson, Hampel, Richardson, Cooper 100 colonoscopy for patients cared for by the Year of publication: 2006 Department of Veterans Affairs Dates of data collection: 1998 - 2003 

Trial name: NA 

KQ3 - Which strategies are effective in NA increasing the appropriate use of colorectal cancer screening and followup? KQ4 - What are the current and NA projected capacities to deliver colorectal cancer screening and surveillance at the population level? KQ5 - What are the effective approaches The authors calculated that the algorithm has approximately 70.1% sensitivity and 71.6% 

for monitoring the use and quality of screening colonoscopy. 

colorectal cancer screening?	 The findings of medical record review were then applied in a sensitivity analysis to recalcu

frequency of screening colonoscopy. Apart from reducing the total number of screening cochanging the definition of screening colonoscopy had little effect on the observed trends. Concordance or kappa not calculated 

QUALITY RATING: Fair 

C-366 
Evidence Table 4. KQ5: Effective approaches for monitoring use and quality of colorectal cancer screening (continued) 

Quality Assessment-Internal Validity for Observational Studies 

C-367 

Were the groups similar at baseline regarding the most important 

Yes No Other (CD, NR, NA) 

NA 

prognostic indicators? Were the drop-out or response rates acceptable (≤ 20%)? [If between X 20% and 60%, check other and explain.] Were the differential drop-out or response rates acceptable (≤ 15%)? X Were intervention/exposure measures valid, reliable, and equally X applied? Were the outcome assessors blinded to the intervention or exposure NA 

status of subjects? Were outcome measures valid, reliable, and equally applied? x Algorithm used to differentiate screening from dia

verified through dual review (see statistical methoConcordance/kappa not calculated 

Does the analysis control for baseline differences? x Logistic regression models used Were important potential confounding and modifying variables taken x into account in the design and analysis (e.g., through matching, stratification, or statistical adjustment)? Were the statistical methods used to assess the abstracted outcomes x appropriate? Quality Rating (Good, Fair, or Poor): Fair 
C-368 

Evidence Table 4. KQ5: Effective approaches for monitoring use and quality of colorectal cancer screening (continued) STUDY:	 Authors, ref ID: Fiscella101 

Year of publication: 2006 Dates of data collection: 1998-2002 Trial name: NR 

OBJECTIVE OR AIM: To determine whether estimates of racial and racial disparities in receipt of six different ty

procedures differ between self-report and Medicare claims data 

DESIGN: Setting: Medicare claims data 

Study design: observational Duration (mean followup): 2 to 4 years Overall study size (N enrolled/N analyzed): 88509 # observations (n = 1474 for colorec

Sample size: 1474 

Describe intervention: Includes fecal occult blood testing, sigmoidoscopy, or colonosco

RECRUITMENT: Population
 (population-based, clinic-based, volunteer, other) INCLUSION CRITERIA: Medicare Beneficiaries 65 and older who participated in the Medicare Current Beneficiary EXCLUSION CRITERIA: Participated in facility interviews (i.e., resided in long-term care facilities), were less than 6

(i.e., were Medicare recipients due to having a qualifying disability), reported race/ethnicity 

Hispanic African American, or non-Hispanic White, i.e. majority, were enrolled in a Medicaeligible for Medicare B (or Medicare A and B) coverage dropped due to incomplete claims

POPULATION CHARACTERISTICS:	 Overall 

65-69 16.7% 

Mean age & range (years): 70-74 35.1% Sex (% female): 75-79 26.7% Race: 80-84 14.3% 

85+ 7.2% 

Other: 56% female 

Hispanic, African American 8.8% 

Majority 91.2% 

NA 

Attrition/Drop-out (not available for 

endpoint measurement): Adherence:
 Contamination: Response Rates (e.g. for surveys): STATISTICAL ANALYSES: Describe: used SAS Survey and logistic regression to assess the relationship, adjusted, b

self report 

ASSESSMENT OF EXPOSURES AND Predictors of self report POTENTIAL CONFOUNDERS: OUTCOME ASSESSMENT: Outcome Measures: 
Evidence Table 4. KQ5: Effective approaches for monitoring use and quality of colorectal cancer screening (continued) 

STUDY:	 Authors, ref ID: Fiscella101 

Year of publication: 2006 Dates of data collection: 1998-2002 Trial name: NR 

• Prevalence of receipt of FOBT, FS, or colonoscopy as measured by: 

• Self-report in the MCBS of having any of the tests in the last year (MCBS) (i

• Medicare claims, including both screening and diagnostic codes (administra

RESULTS: KQ2 - What factors influence the use of NA colorectal cancer screening? KQ3 - Which strategies are effective in NA increasing the appropriate use of colorectal cancer screening and followup? KQ4 - What are the current and NA projected capacities to deliver colorectal cancer screening and surveillance at the population level? 

C-369 

KQ5 - What are the effective approaches for monitoring the use and quality of colorectal cancer screening? 

Outcomes: Unadjusted prevalence of CRC screening White: Survey 38.0 Administrative 30.1 Minority: Survey 34.8 Administrative 20.4 Concordance between self-report and administrative data (measured by kappa score) for White 0.37 Minority 0.19 

The authors also calculated an odds ratios for reporting a procedure in the absence o

Minorities were more likely to report receipt of CRC screening in the absence of a claim (O

2.79), with little change after adjustment for age, gender, income, educational level, health 

and supplemental insurance. Having a claim for CRC testing in the absence of self-reporethnicity. 

QUALITY RATING: Good 
Evidence Table 4. KQ5: Effective approaches for monitoring use and quality of colorectal cancer screening (continued) 

Quality Assessment-Internal Validity for Observational Studies Were the groups similar at baseline regarding the most important prognostic indicators? 

Yes No Other (CD, NR, N

NA 

Were the drop-out or response rates acceptable (≤ 20%)? [If between 20% and 60%, check other and explain.] 

Response rate for Possible that non-respondents in terbetween self repoclaims. 

Were the differential drop-out or response rates acceptable (≤ 15%)? 

Were intervention/exposure measures valid, reliable, and equally applied? Were the outcome assessors blinded to the intervention or exposure status of subjects? Were outcome measures valid, reliable, and equally applied? Does the analysis control for baseline differences? Were important potential confounding and modifying variables taken into account in the design and analysis (e.g., through matching, stratification, or statistical adjustment)? Were the statistical methods used to assess the abstracted outcomes appropriate? Quality Rating (Good, Fair, or Poor): Good 

x 

x 

x 

x 

NA 

NA 

C-370 
C-371 

Evidence Table 4. KQ5: Effective approaches for monitoring use and quality of colorectal cancer screening (continued) STUDY: Authors, ref ID: Hall et al.102 

Year of publication: 2004 Dates of data collection: December 1999 – June 2001 Trial name: NA 

OBJECTIVE OR AIM: To examine the accuracy of self-reports of prostate and colorectal cancer testing and reasons for testing using 

national surveys, the authors conducted a survey and reviewed the medical records for procedures performed 

health maintenance organizations (HMOs) 

DESIGN: Setting: member lists of Kaiser Permanente-Northern California (NC), Kaiser Permanente- Georgia (GA), and 

Minnesota Study design: cross-sectional Duration (mean follow-up): NA Overall study size (N enrolled/N analyzed): 3546 

Black men White and other men 

Sample size: 363 847 

Describe intervention: RECRUITMENT: H.M.O. population based 

(population-based, clinic-based, volunteer, other) INCLUSION Men aged 45 years and older and women aged 55 years and older as of September 1, 1999 who had been enCRITERIA: 5 years were eligible for selection. 

Simple random sample for women. For men, an SRS for men at one site. At 2 sites, separate sample of black until all strata were filled. Also at one site, sample was drawn from members who had participated in a past su

EXCLUSION Screened out (statrum filled); language barrier, dead, out of network, phone disconnected, other CRITERIA: POPULATION 

CHARACTERISTICS: Characteristics of study sample from 3 HMO’s Mean age & range Black men (n=363) White and other men (n = 847) Women (n = 920) (years): 

% 

(n) % (n) % (n) 

Sex (% female): Age (y) Race: 45 – 49 19.8 (72) 14.3 (121) 0.0 0 

50 – 59 41.0 149 38.6 327 23.3 (214

Other: 60 – 69 19.3 (70) 23.4 (198) 33.8 (311

70+ 19.8 (72) 23.7 (201) 42.9 (394Ethnicity Hispanic 0.6 (2) 3.5 (30) 3.2 (29) 

 Non-Hispanic 99.4 (361) 96.5 (816) 96.8 (888Education  < HS 10.2 (37) 6.3 (53) 9.9 (91) HS/GED 22.6 (82) 17.9 (152) 27.1 (249
Evidence Table 4. KQ5: Effective approaches for monitoring use and quality of colorectal cancer screening (continued) 

STUDY: Authors, ref ID: Hall et al.102 

Year of publication: 2004 Dates of data collection: December 1999 – June 2001 Trial name: NA 

C-372 

Some college/tech 38.8 (141) 31.6 (268) 35.7 (328

school  College grad 28.4 (103) 44.2 (374) 27.2 (250Marital status Married 78.0 (283) 82.4 (698) 55.8 (512

Unmarried 22.0 (80) 17.6 (149) 44.2 (406

Employment  Employed 62.9 (227) 59.2 (499) 31.5 (288

Retired 33.8 (122) 39.3 (331) 62.0 (566

Unemployed 3.3 (12) 1.5 (13) 6.5 (59) 

/other Income  <= $20,000 13.6 (46) 9.4 (72) 29.5 (236 $20,000 - $40,000 24.2 (82) 16.9 (130) 30.0 (240 $40,001 - $60,000 23.9 (81) 25.8 (199) 21.4 (171 > $60,000 38.3 (130) 47.9 (369) 19.0 (152Health status  Excellent/ good 82.3 (298) 87.6 (741) 82.1 (754 Fair / poor 17.7 (64) 12.4 (105) 17.9 (164Smoking status Current 17.9 (65) 10.0 (85) 7.5 (69) Former 46.6 (169) 49.9 (423) 36.2 (333

Never 35.5 (129) 40.0 (339) 56.3 (518

Attrition/Drop-out Response Rates (for survey): (not available for 4,833 members contacted endpoint 3,546 eligible measurement): 1,248 refused Adherence: 2,298 completed Contamination: Response rate = 64.8% among those contacted and eligible 

1181 not contacted (no answer, busy, answering service, exceeded call limit) 

STATISTICAL The authors analyzed the data according to our sampling frame, that is, for all women, black men, and white a

ANALYSES: Few participants were of races other than white or black (67 [3.1%] were of other races and 83 [3.9%] were mu

Black men of other races and multiracial men were grouped together with white men. At HP, few men were bla

presented for them. Participants with a history of prostate or colorectal cancer were excluded from the analysewere 363 black men, 847 white and other men, and 920 women. Respondent characteristics were summarized as frequencies and percentages. The authors calculated the per

who reported having had their most recent DRE, PSA, or FOBT within 2 years before interview and sigmoidosc5 years before interview. The percentages of respondents who had tests as determined by the medical record calculated; for FOBT, the authors counted only home kits to match with the survey question. On the basis of th
Evidence Table 4. KQ5: Effective approaches for monitoring use and quality of colorectal cancer screening (continued) 

STUDY: Authors, ref ID: Hall et al.102 

Year of publication: 2004 Dates of data collection: December 1999 – June 2001 Trial name: NA 

C-373 

authors calculated the concordance (agreement) between the self-report and medical record audit for the testscalculated agreement for endoscopy by combining sigmoidoscopy and colonoscopy. The authors calculated the kappa statistic by the method of Landis and Koch, which accounts for agreement exExcellent agreement is defined as a kappa statistic greater than 0.75, fair to good agreement as 0.40 to 0.75, athan 0.40. The authors also calculated the sensitivity and specificity of self-reports using the information from t

standard. Differences in sensitivity and specificity between health plans were determined with a pairwise test o

assessed the relationships between agreement and demographic characteristics (age, sex-race groups, and e

regression models. The reference was agreement between self-reports and medical records and was compareunderreporting. The authors also assessed the relationship with income, but because of the relatively large numobservations and no significant associations in any of the models, it was not included in the final models. All an

study site. Further, the authors determined the reasons for testing and the concordance between the reasons reported by 

reasons recorded in the medical records. Tests were defined as screening tests when the reason for testing wa

or ‘‘part of exam/ doctor just did it.’’ Tests were defined as being performed for ‘‘other reasons’’ when the reasoproblems, follow-up of an abnormal test, or other reasons. Finally, the authors evaluated whether and how freqconfused sigmoidoscopy and colonoscopy. 

ASSESSMENT OF Computer assited telephone interviews (CATI): The survey instrument elicited information on demographic 

EXPOSURES AND including a personal or family history of prostate or colorectal cancer, whether they had ever been tested for prPOTENTIAL and, if so, when they had the most recent tests (see Appendix for the questions asked). In addition, participanCONFOUNDERS: for testing and the test results. The initial questions on prostate and colorectal cancer testing were based on th

the Year 2000 National Health Interview Survey Cancer Control Supplement and Behavioral Risk Factor Survequestionnaire is available from the authors upon request. Medical record reviews: Medical records were reviewed to determine whether any of the cancer tests include

recorded within 5 years before the interview date. In addition, the dates and results of the tests were obtained. the medical records, the authors ascertained the reason for or symptoms associated with the test by reviewing months before the test date but no more than 5 years before the survey (index) date. At each site, each page o

records in the study time period was physically reviewed by a trained medical record analyst. Each provider no

endoscopy, and pharmacy information were abstracted using a standardized medical record abstraction form. 

included a review of all abstraction forms for missing data and ambiguous responses and duplicate abstraction 

Data entry for all forms was conducted at Kaiser Permanente- NC with double key entry. Programs for internal were used to identify and correct errors of coding and data entry. 

OUTCOME (see above) ASSESSMENT: RESULTS: KQ2 - What factors NA influence the use of colorectal cancer screening? KQ3 - Which NA 
Evidence Table 4. KQ5: Effective approaches for monitoring use and quality of colorectal cancer screening (continued) 

STUDY: Authors, ref ID: Hall et al.102 

Year of publication: 2004 Dates of data collection: December 1999 – June 2001 Trial name: NA 

strategies are effective in increasing the appropriate use of colorectal cancer screening and follow-up? KQ4 - What are the current and projected capacities to deliver colorectal cancer screening and surveillance at the population level? KQ5 - What are the effective approaches for monitoring the use and quality of colorectal cancer screening? 

NA Percentage of respondents who received prostate or colorectal cancer tests according to self-report and medic2001 

Black men (n=363) White + other men (n=847) Women (n = 920) % (n) % (n) % (n) 

FOBT* Survey 22.2 (79) 20.3 (169) 25.9 (234) Med recs 11.6 (42) 9.5 (80) 14.1 (129) Sig’oscpy**  Survey 38.4 (138) 42.0 (352) 50.0 (447) Med rec 29.6 (107) 30.6 (258) 34.1 (313) C-scope**  Survey 13.7 (49) 14.6 (121) 15.7 (140) Med rec 8.1 (29) 11.1 (94) 9.6 (88) End’scopy**  Survey 44.4 (159) 49.9 (415) 58.6 (523) Med rec 34.4 (124) 37.8 (319) 39.8 (365) Note: endoscopy indicates sigmoidoscopy OR colonoscopy 

* test within past 2 years 

** test within past 5 years 

CRC screening information: agreement between self-reports and medical record audits, 1999 - 2001 

procedure Black men White and other men Women 

n 

sens spec conc K n sens spec conc K n sens 

Kaiser Permanente-Georgia Fobt 187 0.89 0.86 0.86 0.57 293 0.90 0.85 0.86 0.56 310 0.89 

Sig 188 0.84 0.81 0.82 0.56 294 0.95 0.86 0.89 0.77 310 0.87 

C-374 
Evidence Table 4. KQ5: Effective approaches for monitoring use and quality of colorectal cancer screening (continued) 

STUDY: Authors, ref ID: Hall et al.102 

Year of publication: 2004 Dates of data collection: December 1999 – June 2001 Trial name: NA 

C-375 

Col 185 0.56 0.93 0.90 0.43 292 0.73 0.95 0.91 0.69 309 0.81 End 186 0.87 0.83 0.84 0.64 294 0.96 0.88 0.92 0.83 311 0.95 Kaiser Permanente – northern California Fobt 165 0.73 0.86 0.85 0.29 271 0.72 0.86 0.85 0.32 304 0.79 

Sig 166 0.83 0.77 0.80 0.58 271 0.80 0.77 0.78 0.53 301 0.83 Col 165 0.67 0.88 0.87 0.36 270 0.80 0.93 0.92 0.60 300 0.95 end 165 0.93 0.76 0.82 0.65 269 0.91 0.75 0.81 0.62 299 0.91 HealthPartners, Minnesota Fobt 4 NA NA NA NA 269 0.59 0.87 0.84 0.31 287 0.55 Sig 4 NA NA NA NA 270 0.77 0.67 0.70 0.38 280 0.86 

Col 4 NA NA NA NA 267 0.69 0.90 0.89 0.38 280 0.73 end 4 NA NA NA NA 267 0.85 0.64 0.71 0.43 279 0.93 

Fobt = fecal occult blood test Sig = flexible sigmoidoscopy Col = colonoscopy End = endoscopy Predictors of agreement between self-reports and medical record audits of crc screening tests, generalized log

Predictor Outcome FOBT Sig Col 

OR 95% CI OR 95% CI OR 

Age (y) 50 – 59 Over 1.69 0.91, 3.13 2.13 1.20, 3.80 6.81 

Under 1.22 0.34, 4.41 3.98 1.20, 13.19 6.86 

 60 – 69 Over 2.8 1.50, 5.25 3.07 1.70, 5.54 9.29 

Under 1.9 0.51, 7.05 3.41 0.99, 11.72 9.95 

 70+ Over 2.78 1.46, 5.29 2.85 1.56, 5.19 14.36 

Under 2.47 0.66, 9.31 4.06 1.18, 13.93 13.91 

Sex/race  White / other men Over 0.92 0.62, 1.37 0.75 0.52, 1.10 0.51 

Under 0.74 0.29, 1.90 0.82 0.45, 1.5 0.86 

women Over 0.9 0.60, 1.34 0.91 0.62, 1.32 0.44 

Under 0.88 0.34, 2.24 0.79 0.43, 1.45 0.34 

Education HS/GED Over 0.87 0.54, 1.4 1.48 0.91, 2.39 1.17 

Under 1.74 0.49, 6.19 1.42 0.63, 3.24 0.93 

Some college / tech school Over 0.73 0.46, 1.16 1.15 0.72, 1.84 0.84 

Under 1.55 0.45, 5.40 1.07 0.48, 2.40 0.92 

College grad Over 0.85 0.54, 1.36 1.24 0.77, 2.00 0.77 

Under 1.6 0.45, 5.70 1.09 0.48, 2.48 0.73 

aReference levels for predictors are: age = 40– 49; sex/race group = black men; education = < high school; all 
Evidence Table 4. KQ5: Effective approaches for monitoring use and quality of colorectal cancer screening (continued) 

STUDY: Authors, ref ID: Hall et al.102 

Year of publication: 2004 Dates of data collection: December 1999 – June 2001 Trial name: NA 

C-376 

site. bReference level for outcome variable is ‘‘agreement’’ between the survey and medical record. 

Over = overreport Under = underreport 

QUALITY RATING: Good Quality Assessment-Internal Validity for Observational Studies 

Yes No 

Were the groups similar at baseline regarding the most important prognostic indicators? 

Were the drop-out or response rates acceptable (≤ 20%)? [If between 20% and 60%, check other and explain.] X 

Were the differential drop-out or response rates acceptable (≤ 15%)? Were intervention/exposure measures valid, reliable, and equally applied? X Were the outcome assessors blinded to the intervention or exposure status of subjects? X Were outcome measures valid, reliable, and equally applied? X Does the analysis control for baseline differences? X Were important potential confounding and modifying variables taken into account in the design and analysis (e.g., through matching, stratification, or statistical adjustment)? 

X 

Were the statistical methods used to assess the abstracted outcomes appropriate? X 

Quality Rating (Good, Fair, or Poor): Good 
C-377 

Evidence Table 4. KQ5: Effective approaches for monitoring use and quality of colorectal cancer screening (continued) STUDY: Authors, ref ID: Haque et al.103 

Year of publication: 2005 Dates of data collection: Trial name: NA 

OBJECTIVE OR AIM: The goal of this study was to develop an automated data algorithm designed to distinguis

endoscopy (sigmoidoscopy and colonoscopy) exams. The authors assessed the algorithmclassify the exams using paper medical records as the “gold standard.” 

DESIGN: Setting: Kaiser Permanente Southern California (KPSC) cares for approximately 3 millio

are older than 50 years and targeted for colorectal cancer screening. Automated data traccare received. Study design: cross-sectional Duration (mean follow-up): Overall study size (N enrolled/N analyzed): Stratified random sample of 220 medical re

Sample size: 

Had Colonoscopies 

110 

Had Sigmoidoscopies 110 

Describe intervention: RECRUITMENT: HMO based (Kaiser Permanente) (population-based, clinic-based, volunteer, other) INCLUSION CRITERIA: Participants included all health plan members between the ages 50 and 70 years, who we

from 1998 to 2002, and completed an endoscopy during those years. Stratified random sample based on the algorithm’s classification. 110 FS, 30 classified as screening, and 110 COLON, 30 diagnostic and 80 screening. 

EXCLUSION CRITERIA:	 Participants with a history of colorectal cancer were excluded (N = 1972). 

Of the 220, 32 excluded due to mismatches in participants endoscopy dates. 

POPULATION CHARACTERISTICS: NA Mean age & range (years): 

Sex (% female): Race: Other: 

NA 

Attrition/Drop-out (not available for 

endpoint measurement): Adherence:
 Contamination: Response Rates (e.g. for surveys): STATISTICAL ANALYSES: The authors conducted cross-tabulations between the algorithm and medical review class

sensitivity, specificity, and κ. The classification after medical record review was considere
Evidence Table 4. KQ5: Effective approaches for monitoring use and quality of colorectal cancer screening (continued) 

STUDY: Authors, ref ID: Haque et al.103 

Year of publication: 2005 Dates of data collection: Trial name: NA 

C-378 

Sensitivity indicates the probability that a diagnostic endoscopy was classified as such by Specificity indicates the probability that a nondiagnostic endoscopy was classified as screoverall agreement between the two sources. 

ASSESSMENT OF EXPOSURES AND NA POTENTIAL CONFOUNDERS: OUTCOME ASSESSMENT: Endoscopies were identified using International Classification of Disease (ICD 9 CM) and 

Technology-4 codes.In instances in which a participant completed multiple endoscopies in authors retrieved data for the first endoscopy. FOBT (due to poor sensitivity) and BE (due included in the study. The algorithm used automated data to presumptively classify the endoscopies as diagnosEndoscopies were classified as diagnostic if automated data included certain gastrointestprior to the exam, or signs or symptoms or a FOBT in the 45 days prior. The study gastroeidentified the conditions and signs and symptoms likely to result in diagnostic endoscopieswere classified into the screening group. Two trained abstractors reviewed medical records from 1997 to 2002 to confirm endoscopassessed screening or diagnostic indications for the endoscopies, including the presence conditions or signs and symptoms. To minimize interrater variability, one abstractor reviewrecords classified as a diagnostic exam while the second reviewed all participants’ medicascreening exam. Abstractors classified the endoscopies as diagnostic if the exam was a foabnormality or when clear-cut conditions or signs and symptoms were present, using the as the algorithm. All other endoscopies were classified as screening. 

RESULTS: KQ2 - What factors influence the use of NA colorectal cancer screening? KQ3 - Which strategies are effective in NA increasing the appropriate use of colorectal cancer screening and followup? KQ4 - What are the current and NA projected capacities to deliver colorectal cancer screening and surveillance at the population level? KQ5 - What are the effective approaches The sensitivities for identifying diagnostic sigmoidoscopy and colonoscopy were 48.1% anfor monitoring the use and quality of The algorithm missed most of the diagnostic endoscopies. Conversely, the sensitivities focolorectal cancer screening? sigmoidoscopy and colonoscopy were high (87.9% and 84.4%, respectively) but were ass

specificities. Comparison of classification by automated algorithm versus medical record review 
Evidence Table 4. KQ5: Effective approaches for monitoring use and quality of colorectal cancer screening (continued) 

STUDY: Authors, ref ID: Haque et al.103 

Year of publication: 2005 Dates of data collection: Trial name: NA 

Classification by medical record review 

Classification by Diagnostic Screening % sensitivity % specific

automated (n = 90) (n=98) 

algorithm Sigmoidoscopy Diagnostic 13 8 48.1 (13/27) 12.1 (8/66

 Screening 14 58 87.9 (58/66) 51.9 (14/2

Total 27 66 

Colonoscopy Diagnostic 15 5 23.8 (15/63) 15.6 (5/32 Screening 48 27 84.4 (27/32) 76.2 (48/6

Total 63 32 

The authors conclude that studies relying solely on automated data overestimate screeninconsidered. They also conclude that the automated algorithm needs further improvements screening from diagnostic exams. 

C-379 

QUALITY RATING: Fair 
C-380 

Evidence Table 4. KQ5: Effective approaches for monitoring use and quality of colorectal cancer screening (continued) Quality Assessment-Internal Validity for Observational Studies 

Yes No 

Were the groups similar at baseline regarding the most important prognostic indicators? Were the drop-out or response rates acceptable (≤ 20%)? [If between 20% and 60%, check other and explain.] Were the differential drop-out or response rates acceptable (≤ 15%)? 

Were intervention/exposure measures valid, reliable, and equally applied? X 

Were the outcome assessors blinded to the intervention or exposure status of subjects? X 

Were outcome measures valid, reliable, and equally applied? X 

Does the analysis control for baseline differences? Were important potential confounding and modifying variables taken into account in the design and analysis (e.g., through matching, stratification, or statistical adjustment)? Were the statistical methods used to assess the abstracted outcomes appropriate? Were data inputs valid? X Was an appropriate search strategy used to find data inputs? X Were the calculations and statistical analyses adequate? X Were appropriate sensitivity analyses conducted (especially for any variables that were not based on data from 

CD 

literature)? Other considerations: X Quality Rating (Good, Fair, or Poor): Fair 
Evidence Table 4. KQ5: Effective approaches for monitoring use and quality of colorectal cancer screening (continued) 

STUDY: Authors, ref ID: Pignone et al 104 Yield of claims data and surveys for Year of publication: 2009 determining cancer screening among Dates of data collection: health plan members Trial name: CHOICE OBJECTIVE OR AIM: To evaluate the independent and combined yield of claims and direct survey for identifyin

screening among average risk health plan beneficiaries. 

DESIGN: Setting: 32 Primary care practices in Georgia, Florida taking part in a randomized trial of 

practice-level academic detailing Study design: Observational Duration (mean followup): 2005-2007 

Overall study size (N enrolled/N analyzed): 2558/1595 (responded to survey) 

Sample size: Group 1 

1595 

Describe intervention: none 

C-381 

RECRUITMENT: Claims data from Aetna 

(population-based, clinic-based, volunteer, other) INCLUSION CRITERIA:	 Members with ages between 52 and 80 years whose primary care physicians had agreed 

CHOICE study 

EXCLUSION CRITERIA:	 Individuals at increased risk for colorectal cancer (because the intervention was designed 

or with medical conditions that would limit their ability to participate in the study or who mireasonable candidates for screening. Above average-risk persons were defined as adults colorectal cancer or polyps, a known history of colorectal cancer or polyps in a first-degree history of inflammatory bowel disease also, dementia, chronic obstructive pulmonary diseartery disease, current treatment for cancer or history of metastatic cancer, cirrhosis, uppe

bleeding, unintentional weight loss of >10% within 6 months, blindness, or uncorrectable hexcluded, the individual had to have at least two claims with either a diagnosis or proceduhad one of these additional conditions. 

POPULATION CHARACTERISTICS:
 

Mean age & range (years): Sex (% female): Race: Other: 

Group 1 

Age group 

52-59 887 (69.90) 60-64 283 (22.30) 

65-69 81 (6.38)
 70-82 18 (1.42)
 

% female 60% 

75% white/ 19% black/ 6% other 

Attrition/Drop-out (not available for Overall endpoint measurement): Adherence:
 Contamination: 

Response rate was 62% 

Response Rates (e.g. for surveys): 

STATISTICAL ANALYSES: Describe: Descriptive analyses, logistic regression and examination of confounders 
Evidence Table 4. KQ5: Effective approaches for monitoring use and quality of colorectal cancer screening (continued) 

STUDY: Authors, ref ID: Pignone et al 104 Yield of claims data and surveys for Year of publication: 2009 determining cancer screening among Dates of data collection: health plan members Trial name: CHOICE ASSESSMENT OF EXPOSURES AND Yes POTENTIAL CONFOUNDERS: OUTCOME ASSESSMENT: Outcome Measures: primary outcome was proportion of persons up to date with CRC sc

Survey asked about individuals completion of CRC screening, whether even had and wheClaims data on CRC screening, including FOBT (within 1 year), FS (5 years), colonoscopyears), including most recent data for each type. Indication for the procedure was not spe

RESULTS: KQ2 - What factors influence the use of NA colorectal cancer screening? KQ3 - Which strategies are effective in NA increasing the appropriate use of colorectal cancer screening and followup? KQ4 - What are the current and NA projected capacities to deliver colorectal cancer screening and surveillance at the 

C-382 population level? KQ5 - What are the effective approaches for monitoring the use and quality of 

colorectal cancer screening? 

Outcomes: 

•	 Of 4,020 average-risk members identified, claims data indicated that 1,066 (

cancer screening. Among the 1,269 average risk members with no evidence data who returned surveys, 498 (39%) reported being up-to-date with screen

•	 Combining claims data and survey data: 

•	 Prevalence of CRC screening, combining claims data plus self-reported data 

nonresponders to the survey): 47% 

•	 Prevalence of CRC screening, combining claims data plus self-reported data 

were screened at the same rate as average-risk responders): 59% 

QUALITY RATING: Fair 
Evidence Table 4. KQ5: Effective approaches for monitoring use and quality of colorectal cancer screening (continued) 

Quality Assessment-Internal Validity for Observational Studies Were the groups similar at baseline regarding the most important prognostic indicators? 

Yes No Other (CD, NR, NA) 

NA 

Were the drop-out or response rates acceptable (≤ 20%)? [If between 20% and 60%, x 62% response rate 

check other and explain.] Were the differential drop-out or response rates acceptable (≤ 15%)? Not known 

Were intervention/exposure measures valid, reliable, and equally applied? NA Were the outcome assessors blinded to the intervention or exposure status of subjects? NA 

Were outcome measures valid, reliable, and equally applied? x However, screening vs. diagno

distinguished 

Does the analysis control for baseline differences? NA Were important potential confounding and modifying variables taken into account in the NA design and analysis (e.g., through matching, stratification, or statistical adjustment)? Were the statistical methods used to assess the abstracted outcomes appropriate? x 

Quality Rating (Good, Fair, or Poor): Fair 

C-383 
C-384 

Evidence Table 4. KQ5: Effective approaches for monitoring use and quality of colorectal cancer screening (continued) STUDY: Authors, ref ID: Schenck 105-106 Data sources for measuring colorectal Year of publication: 2007 and 2008 endoscopy use among Medicare enrollees Dates of data collection: 1998-2002 Evaluation of claims, medical records, and Trial name: self-report for measuring fecal occult blood testing among Medicare enrollees in fee for service OBJECTIVE OR AIM: Comparison of different data sources used for measuring CRC testing DESIGN: Setting: 

Study design: Observational Duration (mean followup): Brief Overall study size (N enrolled/N analyzed): 936 eligible 561 analyzed 

Sample size: Overall 

561 

Describe intervention: NA endoscopy and FOBT RECRUITMENT: Population – NC Medicare patients from 10 different counties (population-based, clinic-based, volunteer, other) INCLUSION CRITERIA: North Carolina Medicare enrollees, African American or white, in fee for service Medicare

without history of CRC, who had responded to a 2002 survey. 

EXCLUSION CRITERIA: HMO coverage or gap in coverage POPULATION CHARACTERISTICS: Overall 

50-64 10.5% 

Mean age & range (years): 65-74 62.7% Sex (% female): 75-80 26.8% Race: 61% female 

African American 23.5% White 76.5% 

Attrition/Drop-out (not available for Overall – NA 

endpoint measurement): Adherence:
 Contamination: Response Rates (e.g. for surveys): Response rate to survey not reported. Sample consisted of 1001 persons who had reSTATISTICAL ANALYSES: Describe: descriptive statistics, report to record ratio to detect bias, concordance amongst ASSESSMENT OF EXPOSURES AND No POTENTIAL CONFOUNDERS: OUTCOME ASSESSMENT: Outcome Measures: 

•	 Sigmoidoscoy, colonoscopy and FOBT (both at home and in office) 

•	 Ever use of an endoscopic procedure measured by survey, and date of mos

last 4 years and colonscopy in last 5 years) 

•	 FOBT, distinguishing in office from home, and whether test was part of a che
Evidence Table 4. KQ5: Effective approaches for monitoring use and quality of colorectal cancer screening (continued) 

STUDY: Authors, ref ID: Schenck 105-106 Data sources for measuring colorectal Year of publication: 2007 and 2008 endoscopy use among Medicare enrollees Dates of data collection: 1998-2002 Evaluation of claims, medical records, and Trial name: self-report for measuring fecal occult blood testing among Medicare enrollees in fee for service 

problem, from survey 

•	 Medical record review (using a hierarchical algorithm to link the patient to a 

endoscopic procedure, and whether screening or diagnostic; and dates of fo

•	 Claims (1/1998-12/2002) data using Medicare inpatient, outpatient, and phy

and diagnostic codes were available. 

RESULTS: KQ2 - What factors influence the use of Outcomes: 

colorectal cancer screening? NA KQ3 - Which strategies are effective in Outcomes: increasing the appropriate use of NA colorectal cancer screening and
 followup?
 KQ4 - What are the current and Outcomes: projected capacities to deliver colorectal NA cancer screening and surveillance at the population level?
 

C-385 

KQ5 - What are the effective approaches for monitoring the use and quality of colorectal cancer screening? 

Outcomes: % 

Self report Claim Medical recor

Sigmoidoscopy 22.8 21.6 15.2 Colonoscopy 38.5 35.1 34.1 Endoscopy 50.1 44.9 42.3 

in last 5 yrs NR NR FOBT- home 30.1 FOBT office 31.4 FOBT in last year 28.7 21.2 19.4 

FOBT in last 2 years 44.0 34.2 29.2 

Prevalence of endoscopy in the past year Overall: Survey 50.1 Administrative 44.9 Medical record review 42.3 By sociodemographic characteristics: 
C-386 

Evidence Table 4. KQ5: Effective approaches for monitoring use and quality of colorectal cancer screening (continued) STUDY: Authors, ref ID: Schenck 105-106 Data sources for measuring colorectal Year of publication: 2007 and 2008 endoscopy use among Medicare enrollees Dates of data collection: 1998-2002 Evaluation of claims, medical records, and Trial name: self-report for measuring fecal occult blood testing among Medicare enrollees in fee for service 

Age 55-64; 65-74; 65-80 Survey 50.8; 52.4; 44.0 Administrative 35.6; 43.9; 50.7 Medical record review 32.2; 40.7; 50.0 All African Americans; all whites; all women, all men: Survey 40.9; 52.9; 46.8; 55.3 Administrative 41.7; 45.9; 43.6; 47.0 Medical record review 42.4; 42.2; 42.7; 41.6 Less than high school; high school diploma; more than high school: Survey 28.7; 46.9; 59.8 Administrative 39.4; 45.9; 45.8 Medical record review 38.3; 41.8; 43.6 Prevalence of FOBT in the past year Overall: Survey 28.7 Administrative 21.2 Medical record review: 19.4 By sociodemographic characteristics: Age 55-64; 65-74; 65-80 Survey 35.2; 27.9; 28.4 Administrative 19.3; 21.0; 23.6 Medical record review: 19.3; 19.8; 19.6 All African Americans; all whites; all women, all men Survey 32.0; 27.8; 30.6; 25.9 Administrative 18.8; 22.4; 25.5; 15.3 Medical record review: 12.5; 21.9; 21.7; 16.7 Less than high school; high school diploma; more than high school Survey 26.6; 26.0; 31.6 Administrative 20.2; 20.4; 22.8 
C-387 

Evidence Table 4. KQ5: Effective approaches for monitoring use and quality of colorectal cancer screening (continued) STUDY: Authors, ref ID: Schenck 105-106 Data sources for measuring colorectal Year of publication: 2007 and 2008 endoscopy use among Medicare enrollees Dates of data collection: 1998-2002 Evaluation of claims, medical records, and Trial name: self-report for measuring fecal occult blood testing among Medicare enrollees in fee for service 

Medical record review: 19.1; 16.3; 22.4 Measures of concordance for endoscopy use Administrative to medical record review
 

Agreement: 95 (93-97) Kappa: 0.89 (0.81-0.98) Self-report to medical record review
 Agreement: 70 (66-73) Kappa: 0.39 (0.31-0.47) Self-report to administrative Agreement: 70 (66-74) Kappa: 0.40 (0.32-0.49) Agreement regarding test type (FS or colonoscopy) Claims to medical record review: 93 (88-97)
 Self-report to medical record review: 82 (75-89) Self-report to claims: 77 (70-85) Agreement regarding test purpose (screening or diagnostic): Administrative to medical record review: 52 (43-61) Self-report to medical record review: 65 (55-74) Self-report to administrative: 29 (20-36) Measures of concordance for FOBT Administrative to medical record review
 Agreement: 82 (79-85) Self-report to medical record review
 Agreement: 70 (66-74) 
Evidence Table 4. KQ5: Effective approaches for monitoring use and quality of colorectal cancer screening (continued) 

STUDY: Authors, ref ID: Schenck 105-106 Data sources for measuring colorectal Year of publication: 2007 and 2008 endoscopy use among Medicare enrollees Dates of data collection: 1998-2002 Evaluation of claims, medical records, and Trial name: self-report for measuring fecal occult blood testing among Medicare enrollees in fee for service 

Self-report to administrative Agreement: 67 (63-71) Sensitivity analyses included: excluding claims of FOBT on day of medical visit; including FOBTs (likely including in-office, single card FOBTs with digital rectal exams); did not appmeasures Good 

QUALITY RATING: 

C-388 
Evidence Table 4. KQ5: Effective approaches for monitoring use and quality of colorectal cancer screening (continued) 

Quality Assessment-Internal Validity for Observational Studies Were the groups similar at baseline regarding the most important prognostic 

Yes No Other (CD, NR, N

NA 

indicators? Were the drop-out or response rates acceptable (≤ 20%)? [If between 20% and Survey response 

60%, check other and explain.] possibility that non 

would be different agreement betweeand medical recor

Were the differential drop-out or response rates acceptable (≤ 15%)? NA 

Were intervention/exposure measures valid, reliable, and equally applied? NA Were the outcome assessors blinded to the intervention or exposure status of NA 

subjects? Were outcome measures valid, reliable, and equally applied? x Does the analysis control for baseline differences? NA Were important potential confounding and modifying variables taken into account in NA the design and analysis (e.g., through matching, stratification, or statistical adjustment)? Were the statistical methods used to assess the abstracted outcomes appropriate? x C-389 Quality Rating (Good, Fair, or Poor): Good
Evidence Table 4. KQ5: Effective approaches for monitoring use and quality of colorectal cancer screening (continued) 

STUDY: Authors, ref ID: Schneider EC, et al.107 

Year: 2008 Trial Name: 

RESEARCH OBJECTIVE OR AIM: Evaluate quality measures by describing a field test of the colorectal cancer screening me

Health Plan Employer Data and Information Set of the National Committee for Quality Ass

DESIGN: Setting: 5 geographically dispersed healthcare plans that enrolled 189,193 considered el

Study design: Observational Duration (mean follow-up): Overall study size (N enrolled/N analyzed): 1000 plus an additional random sample of 4the original health care plan cohort (3000 enrollees) 

INTERVENTIONS: NA Sample size: Describe intervention: RECRUITMENT: Each of the 5 enrolled health plans identified all enrollees > 51 y/o, sent this to RAND Cor(population-based, clinic-based, Research staff at RAND Corp. randomly selected 1000 enrollees (200 per plan) who lackevolunteer, other) screening (based on administrative data). Then, medical record abstractors looked for ev

these pts. Health plan also surveyed patients via mail. During a 6 week period, nonrespomailings + a reminder postcard and a final overnight mailing. Response rate was 48.1% (

INCLUSION CRITERIA: > or = 51 y/o continuously enrolled for at least 2 years in one of the 5 health plans EXCLUSION CRITERIA:	 NR

C-390 

POPULATION CHARACTERISTICS: 

Survey respondents older, longer enrollment 

Mean age & range (years): Survey respondents more likely than non respondents to have evidence of CRC screening Sex (% female): Ethnicity: Other: OUTCOME ASSESSMENT: Plan A Plan B Plan C Plan D 

Age of plan, y 53 19 17 17 

Submitted cohort 65,241 68,659 28,564 3,561 

aged 51-80 and enrolled continuously for 2 years  Age, mean, y 64.2 60.9 59.7 58.8  Female, % 54.1% 53.0 51.4 52.8 

Enrollment, mo 

73.3 NA 69.1 83.1 

Survey rspndts N=1250 

Age, mean,y 65.9 60.4 60.9 59.4 

Female, % 58.9 51.7 50.2 54.7 

 Enrollment, mo 76.5 NA 75.5 86.4 
Evidence Table 4. KQ5: Effective approaches for monitoring use and quality of colorectal cancer screening (continued) 

STUDY: Authors, ref ID: Schneider EC, et al.107 

Year: 2008 Trial Name: 

Survey N=1349 nonrespondents 

 Age, mean, y 64.6 60.3 59.9 58.8  Female, % 54.2 50.7 52.0 51.8  Enrollment, 81.8 NA 72.0 82.6 

The authors defined, for each data source (administrative, medical record, and survey resneeded to implement all of the measure specifications. The authors developed a list of ou

that represent a prior diagnosis of colorectal cancer, CPT codes related to an acceptable historical CPT codes used within the previous 10 years. For the medical record method, thabstraction tool to collect data on screening tests, clinical risk factors for colorectal cancerlife expectancy and trained experienced nurses from each health care plan during a pilot tprotocol using a common set of records. For the enrollee survey, the authors developed a (based on the Behavioral Risk Factor Surveillance System) that addressed each of the scframes in which they occurred, and a measure of risk status based on report of a family hData from all sources (administrative, survey, and medical record) were linked at the enroanalytic file. For each of the 4 colorectal screening tests, the authors compared across hepercentage of sampled enrollees identified as screened based on administrative data and survey data. The authors could not determine the percentage screened by each test undebecause medical record abstractors were instructed to stop after identifying the occurrenc

single measure that combined all tests, the authors calculated colorectal cancer screening 

based on administrative data only, survey data only, and combined administrative and mehybrid method), weighing the medical record sample to represent the population from whi(unscreened based on administrative data).. Among the survey respondents, the authors 

sampled enrollees’ screening status according to the survey data and the hybrid data. The rate of screening among survey respondents and nonrespondents using the hybrid estima

RESULTS: KQ4 - What are the current and NA projected capacities to deliver colorectal cancer screening and surveillance at the population level? 

C-391 

KQ5 - What are the effective approaches for monitoring the use and quality of colorectal cancer screening? 

Compared with survey non-respondents, respondents were older (60.4 vs. 59.4 years; P_enrollment (73.3 vs. 67.6 months; P = .001), but the 2 groups had similar percentages of f

vs. 51.1%; P = .28). 

Survey respondents were more likely than non-respondents to have evidence of CRC scrp<0.001) The percentage of enrollees having specific tests varied between the administrative and s
Evidence Table 4. KQ5: Effective approaches for monitoring use and quality of colorectal cancer screening (continued) 

STUDY: Authors, ref ID: Schneider EC, et al.107 

Year: 2008 Trial Name: 

C-392 

health care plans A and E, the percentages of enrollees screened by FOBT according to tin health care plan B, the percentage based on survey data was nearly twice that based oin health care plan C, the percentage based on administrative data exceeded that based oprocedural tests (flexible sigmoidoscopy, doublecontrast barium enema, and colonoscopysurvey data were 2 to 3 times higher than the rates based on administrative data. 

Method Plan A Plan B Plan C Plan D 

FOBT Administrative 23.6 15.0 31.1 NA 

Survey 25.4 26.3 20.5 21.8 

Flex Sig Administrative 14.2 17.9 18.4 15.3 

Survey 29.7 39.6 33.9 33.6 

COLON Administrative 12.8 12.1 9.4 10.5 

Survey 19.9 39.0 33.6 33.7 

Using the single measure of screening (based on any 1 of the 4 tests), the percentage of 

colorectal cancer screening varied substantially depending on the data sources used. For plans, the hybrid method produced a higher screening rate than the administrative data mranged from 0 (health care plan A) to 14.9 (health care plan B) percentage points. For all survey data method produced a higher calculated screening rate than the other 2 method

Method Plan A Plan B Plan C Plan D 

Administrative 41.5 (41.1-41.9) 38.6 (38.2-38.9) 47.1 (46.5-47.6) 27.3 (25.8

Survey 53.2 (42.1-64.4) 69.7 (60.3-79.2) 55.0 (41.1-68.8) 62.1 (53.8Hybrid 41.5 (41.1-41.9) 53.5 (48.5-56.8) 52.6 (48.3-56.8) 38.8 (34.3

ANALYSIS: ARE GROUPS COMPARABLE AT BASELINE: ASCERTAINMENT METHODS 

ADEQUATE AND EQUALLY APPLIED: STATISTICAL ANALYIS ADEQUATE: ATTRITION: NA Dropout (not available for endpoint
 measurement): Adherence in control group:
 Contamination in control group: Differential dropouts:
 QUALITY RATING: Fair 
C-393 

Evidence Table 4. KQ5: Effective approaches for monitoring use and quality of colorectal cancer screening (continued) Quality Assessment-Internal Validity for Observational Studies 

Yes No 

Were the groups similar at baseline regarding the most important prognostic indicators? Were the drop-out or response rates acceptable (≤ 20%)? [If between 20% and 60%, check other and explain.] 

Were the differential drop-out or response rates acceptable (≤ 15%)? 

Were intervention/exposure measures valid, reliable, and equally applied? X Were the outcome assessors blinded to the intervention or exposure status of subjects? Were outcome measures valid, reliable, and equally applied? X Does the analysis control for baseline differences? Were important potential confounding and modifying variables taken into account in the design and analysis (e.g., through matching, stratification, or statistical adjustment)? Were the statistical methods used to assess the abstracted outcomes appropriate? 

Quality Rating (Good, Fair, or Poor): Fair 
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D-23 
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D-24 
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D-25 

Appendix E 
Appendix E: Colorectal Cancer Screening Technical Expert Panel (TEP) Members 

TEP Member Affiliation 

David Ahlquist, M.D. Mayo Clinic 

James Allison, M.D. University of California at San Francisco 

Kaiser Permanente Division of Research 

Durado Brooks, M.D., M.P.H. American Cancer Society 

Thomas Imperiale, M.D. Indiana University School of Medicine 

Donald Steinwachs, Ph.D. Johns Hopkins Bloomberg School of Public Health 

Judith Walsh, M.D. University of California at San Francisco 

Colorectal Cancer Screening Peer Reviewers 

Peer Reviewers Affiliation 

Dennis Ahnen, M.D. Denver Department of Veterans Affairs Medical Center and 

University of Colorado Denver School of Medicine 

James Allison, M.D. University of California at San Francisco 

Kaiser Permanente Division of Research 

Durado Brooks, M.D., M.P.H. American Cancer Society 

Deborah Fisher, M.D., M.H.S. Durham Veterans Affairs Medical Center 

Duke University 

Robert Fletcher, M.D., M.Sc. Harvard Medical School 

Sujha Subramanian, Ph.D. RTI International 

Judith Walsh, M.D. University of California at San Francisco 

Evelyn Whitlock, M.D., M.P.H. Kaiser Permanente Northwest 

E-1 
Appendix F
 
Appendix F: Characteristics of Studies 

with Poor Internal Validity 

To assess the quality (internal validity or risk of bias) of studies, we used predefined criteria based on 

those described in the AHRQ Methods Guide for Comparative Effectiveness Reviews (ratings: good, fair, 

poor).1

 Elements of quality assessment for trials included, among others, the methods used for 

randomization, allocation concealment, and blinding; the similarity of compared groups at baseline; 

maintenance of comparable groups; overall and differential loss to followup; and the use of intention-totreat analysis. We assessed observational studies based on the potential for selection bias (methods of 

selection of subjects and loss to followup), potential for measurement bias (equality, validity, and reliability 

of ascertainment of outcomes), adjustment for potential confounders, and statistical analysis. 

In general terms, a “good” study has the least bias and results are considered to be valid. A “fair” study is 

susceptible to some bias but probably not sufficient to invalidate its results. The fair-quality category is 

likely to be broad, so studies with this rating will vary in their strengths and weaknesses. A “poor” rating 

indicates significant bias (stemming from, e.g., serious errors in design, analysis reporting large amounts 

of missing information, or discrepancies in reporting) that may invalidate the study’s results. 

To systematically rate studies, we designed and used a structured data abstraction form. Trained 

reviewers abstracted data from each study and assigned an initial quality rating. A second reviewer read 

each abstracted article, evaluated the accuracy, completeness, and consistency of the data abstraction, 

and confirmed the quality rating. If differences in quality ratings could not be resolved by discussion, a 

third senior reviewer was involved. The full research team met regularly during the article abstraction 

period to discuss global issues related to the data abstraction process. The following lists all the studies 

reviewed and rated as poor quality, with their design and primary reasons for the final rating. 

Study Design Primary Reasons for Poor Quality Rating 

Chan and Vernon, 

20082 RCT High potential for bias. Study had high overall attrition and high 

differential attrition between the control and intervention groups. 

Cronan et al., 2008 Cross-sectional High potential for selection bias. Reporting of enrollment was 

#2836} inadequate and distinguishing between screening and 

Erban et al., 20013 Cross-sectional 

diagnostic testing was not possible. 

High potential for confounding bias. Baseline differences were 

not accounted for and reporting of statistical analysis was 

Farmer et al., 20084 Cross-sectional 

inadequate. 

High potential for selection bias. Study had low response rates 

and high refusal rates. Screening behaviors and frequency of 

routine check-ups differed between responders and 

Fisher et al., 20065 Modeling study 

nonresponders 

High potential that the model assumptions were invalid. Indirect 

costs were not included, future increased costs for use of fecal 

occult blood tests were not included. 

Fitzgibbon et al., 

20076

; 

Ferreira et al., 20057

; 

Wolf et al., 20058 

RCT Cointerventions were not avoided and not assessed, making it 

difficult to determine the actual effect of either intervention. 

Reporting of randomization and blinding was inadequate. 

Friedman et al., 

20019 RCT High potential for selection bias. Study failed to randomize 

subjects adequately. Serious baseline differences between the 

groups were highly likely but difficult to assess with information 

provided. 

Friedman and 

Borum, 200710 Uncontrolled 

Experimental 

High potential for selection and confounding biases. Selection 

methods were inadequate. Study failed to control for 

study confounding in the statistical analysis. 

Ganz et al., 200511 RCT Reporting was inadequate for method of randomization and 

whether outcome assessors were blinded. Article does not 

report baseline screening status or change over time. Statistical 

F-1 
Study Design Primary Reasons for Poor Quality Rating 

methods were inadequate and included no adjustment for 

baseline screening status. 

Goldberg et al., 

200412 RCT Unable to determine potential for selection bias. Major elements 

of the study were not reported, including information on 

randomization process and allocation concealment, blinding of 

outcome assessors, and comparability of the groups at followup. 

Green and Kelly, 

200413 Descriptive/ 

Correlational 

High potential for selection bias. Results were potentially biased 

because the statistical analysis did not include important 

Greiner et al., 200514 Prospective 

potential confounders. 

High potential for selection bias. Attrition rate was high, 

observational measures were not validated, and the statistical analysis did not 

include important potential confounders. Comparability of the 

groups at followup was not reported. 

Harewood et al, 

200215 Case-control High potential for selection and confounding biases. Reporting 

of baseline differences between the groups was inadequate and 

Honda, 200416 Cross-sectional 

inadequate controlling for confounding in the analysis. 

High potential for selection bias. Response rate was low and 

the statistical analysis did not include important potential 

confounders. 

James et al., 200217 Cross-sectional High potential for selection bias. Statistical methods inadequate 

to determine which factors are related to CRC screening 

adherence. Reporting inadequate. 

James et al., 2008 Prospective High potential for selection bias. Reporting of response rates 

#1369} cohort and baseline differences was inadequate. Statistical methods 

were inadequate to determine which factors are related to 

outcomes. 

Juon et al., 200318 Retrospective High potential for bias. Reporting was inadequate such that 

cohort determining whether sample characteristics met inclusion 

Lane et al., 200819 RCT 

criteria was not possible. 

High potential for selection bias. Baseline differences of groups 

were not reported adequately and the statistical methods used 

to control for potential differences at baseline were inadequate. 

Lawsin et al., 200720 Cross-sectional 

The attrition rate was high. 

High potential for selection bias. Outcomes measures were not 

validated. Reporting of statistical methods was inadequate to 

determine which factors were related to outcomes. 

Marcus et al., 200521 RCT High potential for selection bias. Reporting was inadequate for 

numerous elements: randomization process, allocation 

concealment, blinding, and baseline characteristics of sample. 

Attrition rate was high. 

Matthews et al., 

200522 Cross-sectional High potential for selection bias. Reporting was inadequate and 

outcomes were not validated. 

Miller et al., 200523 RCT High potential for selection bias. Reporting was inadequate. 

Patel, 200424 Cross-sectional 

Attrition rate was high. 

High potential for selection bias. Reporting was inadequate. 

Potential bias at baseline but difficult to assess with information 

provided. Outcomes not validated and statistical methods did 

not adequately control for potential confounders. Attrition rate 

Powe et al., 200425; 

Powe, 200226

Samuel et al., 200927

 RCT 

 Cross-sectional 

was high. 

High potential for selection bias. Numerous elements were not 

reported, including randomization method and attrition rate. 

High potential for selection bias. Reporting was inadequate on 

Sarfaty and Feng28 Prospective 

issues such as characteristics of sample population. 

High potential for selection bias. Study had no comparison 

cohort group. Reporting of measures and statistical methods was 

inadequate. Important potential confounders were not 

considered. 

Teng et al., 200629 Observational, High potential for selection bias. Statistical analysis did not 

cross-sectional include important potential confounders. Outcomes measures 

(scales) were not validated in Chinese Americans and have not 

F-2 
Study Design Primary Reasons for Poor Quality Rating 

been pilot tested. 

Tessaro et al., 

200630 Cross-sectional High potential for selection bias. Reporting was inadequate, and 

baseline differences were not described adequately. Statistical 

methods were inadequate to determine which factors are related 

to CRC screening adherence. 

Thompson et al ., 

200631 RCT This study was included in KQ2 as a fair quality study but 

received a poor quality rating as a KQ3 include because there 

was high potential for selection bias. Reporting was inadequate, 

Walsh et al., 200532 RCT 

Baseline differences were not described adequately. 

High potential for bias because of contamination. Randomization 

was done at the physician level not the patient level. No 

allocation concealment was done. Several elements were not 

reported, including blinding of outcome assessors, information 

Wong, 33 Cross-sectional 

on comparability of the groups at the patient level, and attrition. 

High potential for measurement bias, selection bias and 

confounding. Reporting was inadequate. Important confounders 

Wolf et al., 200134 Cross-sectional 

were not accounted for in the statistical analysis. 

High potential for selection bias. Analysis did not control for 

Wolf et al., 200635 Observational 

important potential confounding variables. 

High potential for selection bias and confounding. High potential 

for measurement bias (outcome measures not valid and reliable, 

and outcome assessors not masked). Insufficient baseline data 

reported. Statistical analysis did not account for potentially 

important confounders. 

Yepes-Rios et al., 

200636 Cross-sectional Potential for selection bias. Response rate was very low. 

F-3 
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F-5 

Appendix G 

Appendix G: Additional Material for KQ 4 

This Appendix provides supplemental information for KQ4. In addition to the outcomes 

described in Chapter 3, we found data in the included studies on current volume by provider type 

and geographic variation in current volume and additional available capacity. Because these 

measures are related to our outcomes of current volume and additional available capacity, we 

have completed summary tables and text for these and included here as an Appendix. We also 

found four additional studies that reported on current volume and additional available capacity in 

individual states (vs. national level-data reported in Chapter 4). Because results from these 

studies did not change our conclusions from the national data, we have included them also as 

part this Appendix rather than in the main text. 

The following tables and text provide data on three types of studies: current volume by 

provider type; geographic variation in current volume and additional available capacity; and 

current volume and additional available capacity in three states. 

Current Volume of Procedures, by Provider Type 

Study characteristics. Three studies reported on the distribution of provider types for current 

volume of FS and colonoscopy (Table G-1).1-3 No study reported projected capacities based on 

hypothetical scenarios of changes in workforce composition. We rated one study good quality3 

and two as fair quality.1-2 Two studies surveyed physicians and measured current volume and 

provider distribution by self-report of the physician or practice;1,3 one study used claims data 

from two federal insurers (Medicare and TRICARE)2

 to analyze provider type for procedures. 

Overview of results. Studies varied in terms of methods (self-report of procedures vs. claims 

analysis) and had slightly different categorizations of providers. Not surprisingly, results were 

dissimilar in terms of proportion of procedures (flexible sigmoidoscopy [FS] and colonoscopy) 

conducted by different provider types. 

Detailed assessment, FS. A study by the National Cancer Institute (NCI), which surveyed 

three types of endoscopic providers, found that FSs in 2003 were performed by primary care 

physicians (65%), gastroenterologists (25%) and surgeons (11%).1

 Seeff et al.,3 in a survey of a 

national sample of endoscopic facilities, found that FSs were conducted by gastroenterologists 

(44 percent), primary care physicians (25 percent), surgeons (21 percent), and other providers 

(11 percent). 

Detailed assessment, colonoscopy. Across the three studies (which include four different 

samples, as one study included TRICARE and Medicare data as separate samples), the range of 

proportions of colonoscopies conducted by gastroenterologists was 66 to 83 percent; the range of 

proportions of colonoscopies conducted by surgeons was 11 to 33 percent.1-3 In two studies that 

used survey data,1,3 the proportion of colonoscopies performed by primary care providers was 1 

to 2 percent. In the third study,2

 the groups were categorized slightly differently; this study found 

that 10 percent of colonoscopies were performed by internal medicine physicians. 
Table G-1. Current volume of procedures, by provider type 

Author, Year 

Study Design Quality 

Setting Results Rating 

Brown et al., 20031 

Cross-sectional and modeling 

National sample of MDs (primary care 

physicians, general surgeons, 

gastroenterologists) 

Good 

Robertson et al., 20062 Percentage of colonoscopies conducted (in 2001) by: Fair 

Gastroenterologists 66% (Medicare) and 73% (TRICARE) 

Cross-sectional secondary data analysis Internal medicine physicians 10% (Medicare) and 10% 

(TRICARE) 

Medicare and TRICARE populations Surgeons 13% (Medicare) and 11% (TRICARE) 

Other 11% (Medicare) and 6% (TRICARE) 

Seeff et al., 20043 

Cross-sectional 

National sample of endoscopy practices 

Percentage of FSs conducted (in 2000) by: 

Gastroenterologists 25% 

Primary care physicians 65% 

Surgeons 11%
 

Percentage of colonoscopies conducted by: 

Gastroenterologists 66% 

Primary care physicians 1%
 

Surgeons 33%
 

Percentage of FSs conducted (in 2002) by:
 

Gastroenterologists 44% 

Primary care physicians 25% 

Surgeons 21%
 

Other 11% 

Percentage of colonoscopies conducted by: 

Gastroenterologists 83% 

Primary care physicians 2%
 

Surgeons 11%
 

Other 5% 

Fair 

FS, flexible sigmoidoscopy. 

Regional Variation in Colorectal Screening Capacity 

Study characteristics. Three studies3-5 examined how capacity to deliver CRC endoscopic 

screening varies across geographic regions (Table G-2). One study was rated good3 and two fair 

quality.4-5 One study divided the nation into four census regions;3

 two studies examined rural and 

urban differences in CRC endoscopic capacity.4-5 

Overview of results. No conclusions can be made from the very few studies available that 

examine how additional available capacity varies by geographic region. 

Detailed assessment: The single study examining national variation in capacity for CRC 

screening found that additional available capacity for FS and colonoscopy is the lowest in the 

South.3 In the study taking place in Montana,4 urban hospitals had more resources in terms of 

facilities to conduct screening but also less additional available capacity. One-third of the 

population in this state lived in urban areas, where half of the total capacity was located but 

where only one-quarter of the unused capacity was located. In comparison, 65 percent of the 

population lived in rural areas, where half of the total capacity exists, but where three-quarters of 

unused capacity was located. In the study from Arizona,5 the vast majority of endoscopic 

procedures were performed in urban areas, and were colonoscopies in both regions (91% in 

urban and 97% in rural areas). Estimates of additional available capacity were higher in rural 

than in urban areas (53.1% and 35.7% of current volume, respectively). 
Table G-2. Regional variation in current volume and additional available capacity for colorectal cancer 

screening 

Author, Year 

Study Design 

Setting

Seeff et al., 20043 

 Data Collection 

Current volume and additional 

Results 

Additional available capacity for FS and 

Quality 

Rating 

Good 

available capacity estimated colonoscopy greatest in the South in terms of 

Cross-sectional by survey of sample of absolute number as well as percentage of potential 

practices performing FS or volume that is additional available capacity; lowest 

National sample of colonoscopy additional available capacity in terms of absolute 

endoscopy number is the West; in terms of percentage it is the 

practices 

Ballew et al., 20094 Current volume and additional 

Northeast 

Uneven distribution of current volume and Fair 

available capacity estimated additional available capacity in Montana, a large 

Cross-sectional and by survey of all hospitals and and primarily rural state 

modeling ambulatory surgical centers 

Urban hospitals had more resources but also less 

Montana population additional available capacity 

35% of the population lived in urban areas where 

49% of the total capacity was located but where 

only 24% of the unused capacity was located; 65% 

of the population lived in rural areas where 51% of 

the total capacity exists but where 76% of unused 

capacity was located 

Benuzillo, et al., 

20095 Current volume and additional 

available capacity estimated 

Overall, physicians reported performing 8,717 

weekly endoscopic procedures (8,312 in urban and 

Fair 

by survey of 405 in rural areas). 

Cross-sectional gastroenterologists and 

colorectal surgeons While only 5% of all procedures were performed in 

Arizona population rural areas, the additional available capacity was 

greater for rural than urban areas (53.1% and 

35.7% of current volume, respectively). 

FS, flexible sigmoidoscopy. 

State-Level Estimates of Ability of Current Volume or Additional 

Available Capacity of Colonoscopy to Meet Projected Demand, By 

Different Demand Scenarios 

Study characteristics. Four studies examined state-level current volume for colonoscopy;4­

7

three of these also reported additional available capacity for colonoscopy (Table G-3).4-5,7 All 

four studies were rated fair quality and relied on self-report of surveyed providers or endoscopic 

screening facilities. Each study that conducted modeling of demand4,6-7 used census data with 

varying types of refinements to estimate projected demand and ability of capacity to meet that 

demand. One study used projected changes in capacity as part of the calculations;6

 two studies4,7 

described the ability of current capacity to meet projected increased demand (under different 

scenarios). The studies reported data from Arizona, Montana, New Hampshire, and New 

Mexico. 

Overview of results. Differing estimates of current volume were described by two studies; 16 

or 20 colonoscopies per week per provider in New Mexico,7 a similar number in Arizona, 5 and 

approximately 40 colonoscopies per month per provider in Montana.4

 Three studies found 

substantial levels of available, unused capacity: 41 percent of current volume in New Mexico7 

and 63 percent in Montana4

 is available but unused capacity for colonscopy. In Arizona, 36.5% 
of endoscopic capacity is available but unused.5

 Three studies used simple modeling with 

varying assumptions and presented different scenarios of projected demand. The Montana study 

estimated that, using all additional available capacity, the unscreened population in Montana 

could be screened using colonoscopy by 2013.4

 The New Hampshire study6 reported that if 

capacity (measured by current volume) were to rise by 20 percent, with 60 percent of procedures 

available for screening, and if compliance with CRC screening increased to 70 percent, capacity 

would almost meet demand. The New Mexico study concluded that the additional available 

capacity in New Mexico was sufficient to increase the prevalence of screening rates by 15 

percent.7 

Table G-3. State-level estimates of colonoscopy current volume, additional available capacity, and ability to 

meet projected demand 

Author, Year 

Study Design Data Inputs/Model Quality 

Setting Data Collection Description Results Rating 

Ballew et al., Current volume Time to screen all 

20094 and additional unscreened 

available capacity persons with 

Cross-sectional estimated by colonoscopy 

and modeling survey of all estimated using 

hospitals and census data 

Montana ambulatory 

population surgical centers 

Current volume (2008): Fair 

36,636 colonoscopies per year 

54% of procedures for screening 

Additional available capacity of colonoscopy: 

23,096 (63%) 

Using 100% of additional available capacity, full 

coverage by colonoscopy could be achieved by 

2013 

Butterly et al., 

20076 

Cross-sectional 

plus modeling 

New Hampshire 

population 

Benuzillo, et al., 

20095 

Cross-sectional 

Arizona 

population 

Hoffman et al., 

Cross-sectional 

plus modeling 

New Mexico 

population 

Current volume 

estimated by 

surveys of all 

endoscopy sites 

Current volume 

and additional 

available capacity 

estimated by 

survey of 

gastroenterologists 

and colorectal 

surgeons 

Current volume 

and additional 

available capacity 

estimated by 

endoscopist 

survey 

Census data used 

to estimate demand 

at varying rates of 

compliance of entire 

population with 

colonoscopy, 

percentage of 

procedures done for 

screening, and 

increases in 

capacity 

Modeling not 

performed 

Census data used 

to model demand if 

prevalence of 

screening increased 

by 5%-25% 

Current volume (2003-2004): Fair 

Average of 39-43 colonoscopies per endoscopist 

per month 

Average of 60% of colonoscopies conducted for 

screening 

If capacity increases by 20%, at the current rate 

of 60% of procedures for screening, and 

estimated 70% compliance rate, capacity would 

almost meet demand 

Current volume (2004): Average of 20 Fair 

colonoscopies per gastroenterologist and 14 per 

colorectal surgeon per week. Overall 8,717 

endoscopic procedures/week. 

Additional available capacity: 3,183 (36.5%) for 

colonoscopy and FS combined 

Current volume (2001): Fair 

Median of 16 (group practice) or 20 (solo 

practice) colonoscopies per endoscopist per 

week 

Total of 832 per week 

Additional available capacity for colonoscopy : 

342 per week (41%) 

Additional available capacity estimated to 

increase the prevalence of current colonoscopy 

screening by 15% above current levels 

20057 
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