title: Barriers of and facilitators to physician recommendation of colorectal cancer screening.
abstract: BACKGROUND
  Colorectal cancer screening (CRCS) has been demonstrated to be effective and is consistently recommended by clinical practice guidelines. However, only slightly over half of all Americans have ever been screened. Patients cite physician recommendation as the most important motivator of screening. This study explored the barriers of and facilitators to physician recommendation of CRCS.
  
  
  METHODS
  A 3-component qualitative study to explore the barriers of and facilitators to physician recommendation of CRCS: in-depth, semistructured interviews with 29 purposively sampled, community- and academic-based primary care physicians; chart-stimulated recall, a technique that utilizes patient charts to probe physician recall and provide context about the barriers of and facilitators to physician recommendation of CRCS during actual clinic encounters; and focus groups with 18 academic primary care physicians. Grounded theory techniques of analysis were used.
  
  
  RESULTS
  All the participating physicians were aware of and recommended CRCS. The overwhelmingly preferred test was colonoscopy. Barriers of physician recommendation of CRCS included patient comorbidities, prior patient refusal of screening, physician forgetfulness, acute care visits, lack of time, and lack of reminder systems and test tracking systems. Facilitators to physician recommendation of CRCS included patient request, patient age 50-59, physician positive attitudes about CRCS, physician prioritization of screening, visits devoted to preventive health, reminders, and incentives.
  
  
  CONCLUSIONS
  There are multiple physician, patient, and system barriers to recommending CRCS. Thus, interventions may need to target barriers at multiple levels to successfully increase physician recommendation of CRCS.
authors.affiliation: Division of General Internal Medicine, University of Pennsylvania School of Medicine, Philadelphia, PA, USA. carmen.guerra@uphs.upenn.edu
authors.forename: Carmen E
authors.initials: CE
authors.lastname: Guerra
authors.forename: J Sanford
authors.initials: JS
authors.lastname: Schwartz
authors.forename: Katrina
authors.initials: K
authors.lastname: Armstrong
authors.forename: Jamin S
authors.initials: JS
authors.lastname: Brown
authors.forename: Chanita Hughes
authors.initials: CH
authors.lastname: Halbert
authors.forename: Judy A
authors.initials: JA
authors.lastname: Shea
mesh_terms: D000328:Adult; D000368:Aged; D001291:Attitude of Health Personnel; D003113:Colonoscopy / Q000706:statistics & numerical data; D015179:Colorectal Neoplasms / Q000175:diagnosis* / Q000517:prevention & control*; D003144:Communication Barriers; D005260:Female; D019983:Guideline Adherence; D006297:Health Services Accessibility; D006801:Humans; D008297:Male; D008403:Mass Screening / Q000379:methods / Q000706:statistics & numerical data*; D008875:Middle Aged; D009780:Occult Blood; D010358:Patient Participation; D010817:Physician-Patient Relations; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D012812:Sigmoidoscopy / Q000706:statistics & numerical data