J. Eaton et al. Table 1 Effects of appointment type and pro- vider role or gender on ordering rates of abdominal aortic aneurysm screening in a primary care internal medicine clinic Logistic regression analysis Variable Appointment type (general medical exam vs. other exam) Provider gender (male vs. female) Provider type (staff physician vs. other) CI, conﬁdence interval; OR, odds ratio. Visit length and abdominal aortic aneurysm screening Univariate OR (95% CI) 4.5 (2.5–8.4) 1.1 (0.4–1.8) 1.7 (0.8–3.8) P-value <0.0001 0.69 0.15 Multivariate OR (95% CI) 4.5 (2.5–8.4) 0.8 (0.4–1.8) 1.6 (0.7–3.7) P-value <0.0001 0.59 0.26 former smoker, suggesting that the provider was either unaware that the patient had smoked previously or was not fully familiar with the USPSTF screening guidelines. Abdominal aortic aneurysm screening for eligible patients was ordered during 24% of general medical examinations, while screening was ordered during just 6% of other appointment types. Fourteen per cent of staff physician appointments and 9% of non-staff physician appointments resulted in AAA screening ordering. In addition, AAA screening was ordered during 13% of appointments with male providers and 12% of appointments with female providers. No statistically signiﬁcant differences in AAA screening ordering practices were observed between staff physi- cians and other providers or between male and female providers (Table 1). In a multivariate regression analysis adjusted for pro- vider type and gender, patients seen during a general medical examination were signiﬁcantly more likely to have AAA screening ordered than those seen during other appointment types (OR, 4.5 [95% CI: 2.5–8.4], P < 0.0001). For the 57 patients who had AAA screening ordered, the mean number of eligible visits prior to having the screening ordered was 4.1 (95% CI: 3.4–4.8), with a range of 1 to 11. Only 13 (2.9%) of the 442 patients had the screening ordered at the ﬁrst eligible visit. Provider knowledge and attitudes regarding AAA screening A total of 109 of 237 providers responded to the electronic survey, for a 46.0% response rate. Provider perceptions of their own knowledge of AAA screening guidelines varied. Only 19.3% of providers felt that they were very familiar with the guidelines, whereas 46.8% identiﬁed themselves as somewhat familiar, and 33.9% identiﬁed themselves as not familiar (Table 2). However, 65.1% of the respondents identiﬁed the correct frequency of screening (once in a lifetime, assuming that the initial test is normal), and 86.7% recognized men as the appropriate gender for screening. Furthermore, 74.3% identiﬁed current smokers as eli- gible, and 79.0% identiﬁed former smokers as eligible. Slightly more than half of the providers (58.1%) selected the appropriate age range for screening (65 to 75 years) (Table 2). When asked about their personal AAA screening ordering prac- tices, most providers (80.4%) estimated that fewer than 75% of their eligible patients had undergone the recommended screening (Table 2). When asked to estimate the percentage of eligible patients in the clinic as a whole who had undergone the screening, 49.0% of providers estimated that fewer than 25% of clinic patients had, and none of the providers believed that more than 75% of patients had been appropriately screened. © 2011 Blackwell Publishing Ltd Many respondents (64.2%) thought that a lack of provider knowledge contributed to poor AAA screening practices. Almost half of the respondents (48.1%) reported that forgetting to issue the order led to screening failures; 45.3% believed a lack of patient knowledge about screening recommendations was also a contrib- uting factor. Some respondents (41.5%) thought that a physician- dependent ordering system played a role in the low compliance. Most respondents (70.6%) believed that a nurse-directed protocol for ordering AAA screening would improve compliance (Table 2). Discussion This study illustrates that physician reminders alone are insufﬁ- cient for providing the recommended AAA screening to eligible patients. Providers ordered AAA screening for fewer than 15% of patients who met the recommended USPSTF screening criteria. It was rare for screening to occur on the ﬁrst visit, resulting in many missed opportunities (n = 4.1 visits) to screen. The longer visit was an independent predictor of screening for AAA. A provider survey identiﬁed factors that may contribute to the low screening rates and suggested potential solutions, chieﬂy the incorporation of a mul- tidisciplinary approach to preventive care administration. Screening rates and visit time With an increasing number of recommended screening tests coupled with shorter visit times, there is a higher burden on the physician to recall appropriate screening recommendations and remember to order them. It has been estimated that 1773 hours of a physician’s annual time is spent on preventive services [9]. Conse- quently, lack of time has been identiﬁed as an important barrier in delivering preventive care [10,11]. Our study provides further evi- dence that visit time is an important determinant for preventive screening. Patients were more likely to have an AAA screening ultrasound ordered during a longer general medical examination, which usually has more time allotted (40 minutes) and often has a disease-prevention component. During longer medical examina- tions, 24% of eligible patients had the recommended AAA screen- ing ordered, compared with only 6% during shorter visits. Once the provider placed the order, patient follow-through with test completion was 100%. Our results showed that the test itself was not a barrier to completion. This contrasts sharply with colonoscopy screening, in which completion rates approximate 50% [12]. On average, the number of missed opportunities (visits) that occurred for patients for whom screening was ordered was 4.1. The burden of time per visit and preventive screening was illustrated in our survey, in which providers identiﬁed that 595