ABSTRACT
OBJECTIVES: To determine: a) the respondents’ perceptions of 4 unclear or conflicting cancer screening guidelines: prostate specific antigen (PSA) for men over age 50, mammography for women ages 40-49, colorectal screening by fecal occult blood testing (FOBT), and colonoscopy for patients over age 40; and b) the influence of various patient and physician factors on the decision to order these tests.
STUDY DESIGN: National Canadian mail survey of randomly selected family physicians.
POPULATION: Family physicians in active practice (n=565) selected from rural and urban family medicine sites in 5 provinces representing the main regions in Canada: British Columbia, Alberta, Ontario, Quebec, Nova Scotia.
OUTCOMES MEASURED: Agreement with guideline statements, and decision to order screening test in 6 clinical vignettes.
RESULTS: Of 565 surveys mailed, 351 (62.1%) were returned. Most respondents agreed with the Canadian Task Force recommendations, and the majority believed that various guidelines for 3 of the 4 screens were conflicting (PSA 86.6%; mammography 67.5%; FOBT 62.4%). Patient anxiety about cancer, patient expectations of being tested, and a positive family history of cancer significantly increased the odds that the 4 tests would be ordered. A good quality patient-MD relationship significantly decreased the odds of ordering a mammogram. Screening decisions were also significantly influenced by the respondents’ beliefs about whether screening was recommended and whether screening could cause more harm than good. A physician’s sensitivity to his or her colleagues’ practice influenced screening decisions regarding PSA and mammography.
CONCLUSIONS: These results suggest a conceptual framework for understanding the determinants of screening behavior when guidelines are unclear or conflicting.
KEY POINTS
Four factors are significant determinants, independently, of a physician’s decision to order a screening test when recommendations are unclear or conflicting: a patient’s anxiety about having cancer; a patient’s expectation to undergo screening; a family history of cancer; and (in most cases) the quality of the patient-physician relationship. Particularly in the context of breast cancer screening, when a patient and physician have a good relationship, they are more likely than when the relationship is poor to discuss the pros and cons of a conflicting screening guideline and reach a mutually agreeable decision.
In instances of conflicting recommendations, the importance physicians attribute to the practice of colleagues influences their screening decisions.
Although most studies of the determinants of physicians’ cancer screening behavior have dealt with facilitators or barriers to the adoption of guidelines with clear recommendations, virtually no studies have examined factors affecting physician practice when guidelines are unclear or conflicting. When guidelines are unclear, many physicians are left with little direction. By performing cancer screening procedures that are not clearly effective,1 physicians are diverting limited resources to areas where there is uncertain or no benefit to patients.
We studied physician decision-making in cancer screening when guidelines are “unclear” or conflicting. We defined an unclear guideline as a C recommendation (insufficient evidence to recommend the maneuver or not) from the Canadian Task Force on the Periodic Health Examination.2,3 We defined a “conflicting” guideline as one for which there were different recommendations from at least 2 different organizations for the same cancer screening maneuver.
The authors conducted a qualitative study of 10 focus groups across Canada, and identified factors that influence family physicians’ cancer-screening decisions when guidelines are unclear or conflicting.4 The findings supported a conceptual model with 8 factors: 1) patient factors (patient anxiety, expectations, and family history); 2) physician factors (perception of guidelines, clinical practice experience, influence of family physician and specialist colleagues, and time/financial costs; 3) the patient-physician relationship (quality of rapport). Four of these 8 factors were considered the most influential: patient anxiety about having cancer, patient expectations to have a screening test, family history of cancer, and the quality of the patient-physician relationship.
Although we know of many factors that determine cancer-screening decisions, it is not known how much each of these factors contributes to physicians’ decisions to perform tests in specific situations. The aim of this study was to verify these determining factors and to quantify the strength of the influence of each one on cancer screening decisions.
Methods
We conducted a national survey of family physicians in Canada because they are the main preventive care providers in Canada and because a physician’s recommendation is the strongest predictor of an individual’s decision to have a screening test.5
The self-administered questionnaire was mailed to a random sample of 600 family physicians, 120 from each of 5 provincial licensing bodies from 5 regions in Canada: British Columbia, Alberta, Ontario, Quebec, and Nova Scotia. We stratified by postal codes to ensure equal representation of urban and rural physicians (oversampled) to permit subgroup analysis. Ethical approval was obtained from all participating institutions. We followed a modified 4-step Dillman6 method, using initial full mailing, follow up reminder postcards, second full mailing, and phone call reminders.