Primary Care Physicians Performing Screening Colonoscopy: Patient Compliance Improvements and Colorectal Cancer Disparities Reduction Potential

Background: African-Americans (AA) have disproportionately higher case incidence, deaths, aggressive colorectal cancer (CRCA), early onset CRCA, and sigmoidoscopy–missed CRCA than whites. Reducing colorectal cancer disparities will require widely accessible, high-quality colonoscopy screening services, because it can prevent 90% of CRCA cases and deaths, by detecting and removing polyps, the precursors of CRCA. Currently available specialist capacity is able to meet about 50% of the screening colonoscopy need. The question is, will training of AA primary care physicians (PCPs) in screening colonoscopy followed by facilitating its safe and high quality performance by trained PCPs in a full-service endoscopy center increase AA patients' colonoscopy completion rates?

This study was funded through the South Carolina Cancer Disparities Community Network (one of 25 Cancer Network Programs) by the National Cancer Institute. The South Carolina Medical Endoscopy Center has trained 53 primary care physicians, 15 African American, in screening colonoscopy and offers the facility's infrastructure and technical support for trained PCPs to perform procedures independently.

Objective: To compare screening colonoscopy completion rates among age-eligible patients of trained AA PCPs before training and after, and with untrained physicians during comparable time periods.

Methods: We completed medical chart reviews of 200 consecutive colonoscopy-eligible, established patients of each of 7 African-American primary care physicians trained in colonoscopy, along with similar samples for 5 untrained physicians practicing in the same metropolitan area. A total of 2272 chart data are analyzed to compare: a) colonoscopy completion differences among trained physicians' patients before and after training. b) comparable completion differences relative to untrained physicians during the above periods. Adjusted colonoscopy compliance rates will be presented, controlling for patient's race and other demographics, using multi-level modeling.

Results: 1322 trained physicians' patients (90% AA) and 950 untrained physicians' patients (64% AA) were assigned to pre-training and post training periods based on training start date (untrained physicians were matched to trained physicians by practice zip code). Results show increased rates with training PCPs.

Implications: Our findings indicate significantly improved colonoscopy completion among African American patients following training of African American PCPs, relative to before training and to untrained PCPs. Together with evidence of high quality performance, patient safety and case yield levels of PCP-performed colonoscopies at this center in a companion study, the evidence suggests that training AA PCPs in colonoscopy is effective in reaching out to African Americans to reduce colo-rectal cancer disparities by increasing levels of screening.