title: Factors influencing variation in physician adenoma detection rates: a theory-based approach for performance improvement.
abstract: OBJECTIVE
  Interventions to improve physician adenoma detection rates for colonoscopy have generally not been successful, and there are little data on the factors contributing to variation that may be appropriate targets for intervention. We sought to identify factors that may influence variation in detection rates by using theory-based tools for understanding behavior.
  
  
  METHODS
  We separately studied gastroenterologists and endoscopy nurses at 3 Kaiser Permanente Northern California medical centers to identify potentially modifiable factors relevant to physician adenoma detection rate variability by using structured group interviews (focus groups) and theory-based tools for understanding behavior and eliciting behavior change: the Capability, Opportunity, and Motivation behavior model; the Theoretical Domains Framework; and the Behavior Change Wheel.
  
  
  RESULTS
  Nine factors potentially associated with adenoma detection rate variability were identified, including 6 related to capability (uncertainty about which types of polyps to remove, style of endoscopy team leadership, compromised ability to focus during an examination due to distractions, examination technique during withdrawal, difficulty detecting certain types of adenomas, and examiner fatigue and pain), 2 related to opportunity (perceived pressure due to the number of examinations expected per shift and social pressure to finish examinations before scheduled breaks or the end of a shift), and 1 related to motivation (valuing a meticulous examination as the top priority). Examples of potential intervention strategies are provided.
  
  
  CONCLUSIONS
  By using theory-based tools, this study identified several novel and potentially modifiable factors relating to capability, opportunity, and motivation that may contribute to adenoma detection rate variability and be appropriate targets for future intervention trials.
authors.affiliation: Centre for Behaviour Change, University College London, London, United Kingdom.
authors.forename: Louise
authors.initials: L
authors.lastname: Atkins
authors.affiliation: Division of Research, Kaiser Permanente, Oakland, California, USA.
authors.forename: Enid M
authors.initials: EM
authors.lastname: Hunkeler
authors.affiliation: Division of Research, Kaiser Permanente, Oakland, California, USA.
authors.forename: Christopher D
authors.initials: CD
authors.lastname: Jensen
authors.affiliation: Centre for Behaviour Change, University College London, London, United Kingdom.
authors.forename: Susan
authors.initials: S
authors.lastname: Michie
authors.affiliation: Division of Research, Kaiser Permanente, Oakland, California, USA.
authors.forename: Jeffrey K
authors.initials: JK
authors.lastname: Lee
authors.affiliation: Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
authors.forename: Chyke A
authors.initials: CA
authors.lastname: Doubeni
authors.affiliation: Department of Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York, USA.
authors.forename: Ann G
authors.initials: AG
authors.lastname: Zauber
authors.affiliation: Division of Research, Kaiser Permanente, Oakland, California, USA.
authors.forename: Theodore R
authors.initials: TR
authors.lastname: Levin
authors.affiliation: Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA.
authors.forename: Virginia P
authors.initials: VP
authors.lastname: Quinn
authors.affiliation: Division of Research, Kaiser Permanente, Oakland, California, USA.
authors.forename: Douglas A
authors.initials: DA
authors.lastname: Corley
mesh_terms: D000236:Adenoma / Q000175:diagnosis*; D001288:Attention; D002983:Clinical Competence; D003113:Colonoscopy / Q000592:standards*; D015179:Colorectal Neoplasms / Q000175:diagnosis*; D005221:Fatigue; D017144:Focus Groups; D000072102:Gastroenterologists; D006801:Humans; D009042:Motivation; D009726:Nurses; D011582:Psychological Theory; D058996:Quality Improvement; D012931:Social Environment; D016526:Workload