In this study, a patient outreach program failed to support the notion that rates of screening colonoscopy can be increased by offering women the option of a screening colonoscopy performed by a female endoscopist. The study appears in the November issue of GIE: Gastrointestinal Endoscopy, the monthly peer-reviewed scientific journal of the American Society for Gastrointestinal Endoscopy (ASGE).
As of 2005, approximately 50 percent of women aged 50 years and older were up to date with colorectal cancer screening. Since 2000, several surveys eliciting hypothetical preferences have reported that approximately 45 percent of women prefer that their endoscopic screening procedures be performed by female physicians. Another study reported that 61 percent of women would be more willing to undergo a flexible sigmoidoscopy if the endoscopist were a woman. Noting that only a small minority of endoscopists are female, a retrospective study reported that women who preferred a female endoscopist were 15 percent less likely to have been screened than women who did not have this preference. A majority of these authors have concluded that a lack of female endoscopists is an important barrier to screening, and that offering women the choice of a female endoscopist may significantly increase screening rates.
"Despite survey results, this hypothesis has not been evaluated in actual practice. Similarly, the extent to which women request a female endoscopist at the time of scheduling a screening colonoscopy remains unknown," said study lead author Thomas Denberg, MD, vice president, Quality and Safety, Atrius Health. "We conducted a prospective cohort study to evaluate the hypothesis that, given the choice, women who are offered a female endoscopist through an outreach program are more likely to prefer a female endoscopist and more likely to undergo a colonoscopy than women who are not offered this choice. We found that the rates of screening colonoscopy did not increase when women were offered a female endoscopist."
Patients and Methods
Asymptomatic women ages 50 to 69 years old were identified at seven University of Colorado Hospital primary care clinics for this prospective cohort study. Patients who were included in the study had seen their primary care provider within the past 18 months and did not appear to be up to date with their colorectal cancer screening. Patients with significant comorbidities were excluded from the study. A patient outreach program was initiated incorporating team-based care, patient registries, electronic communications and expanded scheduling arrangements. For eligible patients, personalized letters were sent that included information on the patient's eligibility for colorectal cancer screening, the benefits of screening, a recommendation that the patient undergo a colonoscopy, or if recommended by the primary care provider or desired by the patient, an alternative screening test. All letters offered to help patients arrange for screening and included an educational brochure on colorectal cancer screening.
Researchers used two screening colonoscopy invitation strategies that differed in terms of how strongly they advertised the availability of a female endoscopist: the first used invitations that did not include the choice of a female endoscopist; and the second used invitations that included a choice of a female endoscopist both in writing and over the telephone. Each strategy was applied for an average of two months. The written portion of the written plus verbal invitation to request a female endoscopist included, in the one-page flyer, a prominent message that read, "If you prefer for a WOMAN doctor to perform your colonoscopy, be sure to let us know!" along with a cartoon graphic of a woman doctor reading a clipboard.
For patients wishing to proceed with colonoscopy, a medical assistant recorded whether the patient had any "preferences about the procedure in terms of date, time, and doctor performing it." At the time of reviewing recommendations for and the availability of screening colonoscopy, the medical assistants verbally offered the option of a female endoscopist only to patients assigned to the verbal invitation group; patients in the other group were required to initiate this request themselves, either after being prompted about procedure preferences or at any other time. Patients requesting a female endoscopist were scheduled accordingly; otherwise, patients were assigned to any available endoscopist. The study tracked colonoscopy completion for two months after colonoscopy scheduling (the average wait time was four to six weeks).
The final analysis included 396 patients. Without differences based on the mode of invitation, 117 eligible women scheduled a screening colonoscopy and 72 underwent the procedure. After adjustment for baseline characteristics, patients who received a verbal plus written invitation were significantly more likely to request a female endoscopist than patients who received no invitation (44.2 percent vs 4.8 percent). The average waiting time for a screening colonoscopy did not differ between women who did and did not request a female endoscopist. In aggregate, patients who selected a female endoscopist were neither more nor less likely to undergo a colonoscopy than those who did not. Of those patients who received no offer of a female endoscopist (32.5 percent or 203 patients), 19.2 percent underwent a colonoscopy and for those patients who received a verbal offer of a female endoscopist (30.9 percent or 193 patients), 17.1 percent underwent a colonoscopy.
The researchers concluded that in light of other studies, this negative result may not be surprising. For example, 2005 National Health Interview Survey data did not identify a sex difference in completion of endoscopic screening procedures in the past 10 years, and in 2006, a large clinic-based study found no sex difference in adherence to primary care provider screening colonoscopy referrals. Although many women prefer to see female primary care providers and gynecologists for discussions of personal problems or for pelvic examinations, it does not necessarily follow that these are important considerations for single-event screening colonoscopy procedures. Preferences for female endoscopists seem to be common, but additional evidence is needed to support the notion that the lack of female endoscopists is an absolute barrier to screening colonoscopy for large numbers of women.
About the American Society for Gastrointestinal Endoscopy
Since its founding in 1941, the American Society for Gastrointestinal Endoscopy (ASGE) has been dedicated to advancing patient care and digestive health by promoting excellence in gastrointestinal endoscopy. ASGE, with nearly 12,000 members worldwide, promotes the highest standards for endoscopic training and practice, fosters endoscopic research, recognizes distinguished contributions to endoscopy, and is the foremost resource for endoscopic education. Visit www.asge.org and www.screen4coloncancer.org for more information and to find a qualified doctor in your area.
Endoscopy is performed by specially-trained physicians called endoscopists using the most current technology to diagnose and treat diseases of the gastrointestinal tract. Using flexible, thin tubes called endoscopes, endoscopists are able to access the human digestive tract without incisions via natural orifices. Endoscopes are designed with high-intensity lighting and fitted with precision devices that allow viewing and treatment of the gastrointestinal system.
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