Mo1110 A Systematic Review of Patient Provider, and System Barriers to Colorectal Cancer Screening With Colonoscopy in African-Americans

Abstract

Introduction: African-Americans (AAs) are 20% less likely than Caucasians to undergo appropriate colorectal cancer (CRC) screening. The group also carries the greatest burden of disease, as evidenced by the highest: 1) incidence of CRC of any ethnic group; 2) CRC mortality rate; 3) prevalence of polyps at screening colonoscopy; 4) incidence of high-grade dysplasia at age ,50; and 5) incidence of advanced stage at disease presentation. While studies have explored barriers to uptake for screening colonoscopy among AAs, existing literature lacks a comprehensive conceptual framework that synthesizes the contributing patient, provider, and system factors. We sought to systematically review the literature to inform a conceptual framework governing all barriers to colonoscopic screening in AAs. Methods: We conducted a systematic review of Medline and Cochrane databases for studies addressing barriers to colonoscopic CRC screening. Search results were reviewed manually and included if they addressed barriers to uptake of screening colonoscopy, included AAs in the U.S, and were published in English between 1/1/90 and 11/1/12. We then employed a modified Andersen Behavioral Model of Health Service Use as a conceptual framework to construct a model for uptake for screening colonoscopy among AAs in the U.S. ( Table). Results: We identified and reviewed 409 abstracts by two authors; 127 were included in the full-text review process. Of these studies, 34 met criteria for inclusion. 20 (59%) studies presented patient-level barriers to screening uptake, 13 (38%) addressed provider-level barriers, and 8 (24%) presented system-level factors. 16 (47%) studies reported rates of colonoscopy uptake for AAs, which ranged from 14% to 65%. Prominent patient-level barriers were low education level, lack of knowledge about CRC screening, fear of cancer diagnosis, anxiety about procedure discomfort, self-perception of low cancer risk, and direct and indirect costs. Provider-level factors included knowledge deficits about guidelines and lack of screening recommendation. System-level factors included lack of insurance coverage, poor access to care, insufficient time with primary care physicians, inaccessibility of specialist services, absence of reminder systems, and insufficient reimbursement for discussing screening. Conclusions: We identified multiple, modifiable patient, provider, and system-level barriers to CRC screening among average-risk AAs. Heeding these barriers, future interventions should target patient knowledge about the efficacy of colonoscopy screening for preventing CRC, physician knowledge about screening guidelines for AAs, and access to healthcare services. Using focused interventions at the level of the patient, provider, and healthcare system, we may reduce the morbidity and mortality from CRC in this high-risk, under-screened population. Patient, Provider, and System-level Barriers to Colorectal Cancer Screening Among AfricanAmericans. Based on a modified Andersen Model of Health Services Use.