Variations in CRC screening practice: Would this patient be screened?

Purpose: Screening rates for colorectal cancer (CRC) in the United States were below the goal of 50% outlined in Healthy People 2010. Physician recommendation is an important predictor of patient compliance. We compared physician CRC screening decision processes (as depicted in decision trees) and examined how variations in decision processes affected decision outcomes. Further, we examined whether those variations could be attributed to physicians' characteristics and guidelines' utilization. Methods: We conducted semi-structured interviews with primary care physicians, developed decision trees, compared trees, used trees to predict the recommendation for 8 sample patients, and used regression analysis to identify predictors of variation. Results: Most of the physicians (77.3%) self-reported following clinical guidelines for CRC screening. Physicians considered an average of 5.9 decision criteria (range 2-12) in making their screening recommendations. Frequently cited criteria included patient age and family history. We documented variation for 3 of 8 sample patients. Regression analysis indicated that complexity of decision process, gender, age, and experience of physicians contributed to recommendations on screening. In addition, the self-report adherence to guidelines did not influence whether a physician would recommend CRC screening. Conclusions: This study supports the notion that variation in practice is a function of decision processes. Therefore, studying decision processes may facilitate efforts to improve patient outcomes.