Colorectal Cancer Screening Practices among Texas Nurse Practictioners and Physician Assistants

Background:  Cancer now rivals cardiovascular disease as a leading cause of death.  New cases of cancer are projected to increase 42% by 2025.  Colorectal cancer (CRC) is the second leading cause of cancer death when mortality for men and women are combined. CRC is preventable and survivable if appropriate risk stratified screening and surveillance is undertaken. Nurse practitioners (NP) and physician assistants (PA) currently provide essential primary and specialty care. These providers will play an important role in risk stratified cancer screening, co-management with oncologists, and other members of the cancer care team. Knowledge and use of national CRC screening guidelines should be part of NP and PA practice. A review of the literature suggests there is a gap in NP and PA knowledge of risk stratified CRC screening and surveillance guidelines. CRC screening in primary care is under-utilized compared to breast and cervical cancer screening. The purposes of this descriptive correlational study were to: 1) describe the beliefs, attitudes, and practices of Texas NPs and PAs with regard to risk stratified CRC screening and surveillance, 2) determine the associations between  the NP and PA knowledge of CRC screening and surveillance guidelines and their screening practices, and 3) describe the perceived barriers to CRC screening. Theoretical Framework: This study was guided by Azjen’s Theory of Planned Behavior. The theory of planned behavior is an extension of Fishbein & Ajzen’s 1975 Theory of Reasoned Action. According to Ajzen the intention to perform various kinds of action can be predicted by the individual’s attitudes and beliefs about the action, the subjective norms in the individual’s environment, and the perceived behavioral control the individual has over the action. The combination of an individual’s intention and their perceived behavioral control contributes to the variance in actually carrying out the action (Ajzen, 1991). Azjen recognized that there are behaviors over which an individual lacks actual control.

Research Questions: 1) What are the beliefs, attitudes, and practices of Texas NPs and PAs with regard to risk stratified CRC screening in adults? 2) Is there a relationship between NP and PA knowledge of national screening guidelines for adults at varying risk of CRC and their CRC screening behavior? 3) Is there a relationship between provider demographics and CRC screening? 4) What are the barriers to CRC screening identified by NPs and PAs? 

Sample: An email invitation to participate in the study was sent to the 3520 eligible members of the Texas Nurse Practitioner (TNP) organization and the Texas Academy of Physician Assistants (TAPA).  The response rate to the survey was 7%. The convenience sample consisted of 258 non-physician providers: 167 NPs (64%) with a Texas nursing license and who were authorized to practice as an advanced practice registered nurse and 91 PAs (35%) with an active Texas license and who order cancer screening or diagnostic testing in adults. The NPs ranged from 24 to 70 years old (M=50.74, SD10.56). The PAs ranged from 25-75 years old (M= 43.64, SD13.55).  The length of time in the professional role ranged from 1 to 40 years for the NPs (M= 8.9 SD 8.59) and 1 to 40 years for the PAs (M= 12.73 SD 11.10). Methods: This study used a descriptive correlational design. Data were collected with a self-administered web-based questionnaire using Qualtrics® (version 12018) software. The survey instrument for this study was adapted from versions used in previously published studies. The questionnaire consisted of 44 items categorized in three domains: personal and practice demographics, knowledge of national guidelines for risk stratified CRC screening, and providers’ personal practices and perceived barriers to screening. Results: Background factors impacting provider beliefs and attitudes regarding CRC screening included: administrative support, adequate time to screen patients during visits and inclusion of screening even with a mandate to see more patients. Eighty-three percent of NPs and 85.8 % of PAs stated they had adequate administrative support for risk stratified CRC screening. The majority reported having adequate time to screen (NPs 87.5%, n= 146; PAs 84.6%, n=77). Only 39.5%, (n = 60) NPs and 36.3 %,( n= 33) PAs stated the demand to see more patients limited their ability to perform risk stratified CRC screening. Both groups engaged in cancer screening for breast cancer (NPs 88.6%, n=158; PAs 82.4%) and cervical cancer (NPs 80.2 %, n= PAs 74.7% n=) and colorectal cancer screening in particular. Fecal Occult Blood (FOBT) was the most frequent non-invasive CRC screening test used. Slightly more NPs (75%, n= 161) ordered FOBT than PAs (68% n=62). Fecal Immuno-histochemical testing (FIT) was ordered less often by both groups: NPs 15.6% (n =26)  PAs 15.4% (n=14).  Both groups ordered a colonoscopy in average risk patients: NPs 85% (n=142) and PAs 86.8% (n=79).  One hundred thirty (50.2%) of the respondents identified patients' statements of inability to pay the out of pocket cost or lack of insurance coverage for colonoscopy, as reasons they would not order a colonoscopy. Providers refrained from ordering a colonoscopy due to patients’ preference, co-morbidities, and age above the limit for routine screening. Fear and dislike of the bowel preparation required for a complete evaluation of the colon were major reasons patients refused the screening. Patients also were fearful of complications from the procedure and receiving an abnormal result. Other barriers were lack of transportation, a belief that the procedure had no personal benefit to them, or they were just too busy and could not take time away from work. Limitations: Findings from the study should be carefully interpreted due to several limitations. The small sample size was underpowered and limited the statistical analyses. The sample was also restricted to non-physician members of two professional organizations in the state of Texas. Respondents who met the inclusion criteria and initially agreed to participate in the study read some of the items but did not complete the online survey and had to be eliminated from the analyses. Although the items of the questionnaire were used by researchers in previously published articles no psychometric analysis of the questionnaire has been done to date.  Due to these limitations the findings are not generalizable to the wider non-physician provider group in Texas or beyond. Conclusions: The majority of non-physician providers (NPs and PAs) who are members of two professional organizations in the state of Texas use their knowledge of national CRC screening guidelines and administrative support to actively screen their patients at varying risk for colon cancer. Although the providers are willing to order screening colonoscopies their patients continue to voice numerous barriers to completing the procedure.