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pdfFinal Report
for
Contract No. 200-2002-00573
Task Order 0002
Colorado Survey of Endoscopic Capacity
(SECAP)
Submitted to:
Laura Seeff, MD
CDC Technical Monitor
Centers for Disease Control and Prevention
Division of Cancer Prevention and Control
4770 Buford Highway NE, MS K-55
Atlanta, Georgia 30341
and
Sara E Miller, MPA
Director, Comprehensive Cancer Program
Asthma Program Prevention Services Division
Colorado Department of Public Health and Environment
4300 Cherry Creek Drive S A5
Denver, CO 80246
December 2006
Submitted by:
Diane Manninen, Ph.D.
Frederick Dong, A.M.
Linda Winges, M.A.
Centers for Public Health Research and Evaluation
1100 Dexter Avenue N
Seattle, Washington 98109
Colorado Final SECAP report 12/13/06
Table of Contents
Page
1.0 INTRODUCTION.................................................................................................................. 3
2.0 STUDY METHODS............................................................................................................... 3
2.1 OBJECTIVES OF THE STUDY ................................................................................................... 3
2.2 SURVEY DESIGN AND ADMINISTRATION ............................................................................... 3
2.2.1 Development of the survey instrument.......................................................................... 3
2.2.2 Identification of the eligible facilities that perform endoscopy ..................................... 3
2.2.3 Data collection procedures........................................................................................... 3
2.2.4 Region Definitions ........................................................................................................ 3
2.2.5 Survey response rate ..................................................................................................... 3
2.3 ANALYSIS TECHNIQUES ......................................................................................................... 3
2.3.1 Definition of practice specialty...................................................................................... 3
2.3.2 Imputation of missing data ............................................................................................ 3
3.0 CURRENT CAPACITY FOR COLORECTAL CANCER SCREENING AND
FOLLOW-UP ........................................................................................................................ 3
3.1 CHARACTERISTICS OF PROVIDERS AND PRACTICES PERFORMING ENDOSCOPY........................ 3
3.2 NUMBER AND TYPE OF PROCEDURES PERFORMED ................................................................. 3
3.3 MEASURES TO ADDRESS INCREASED NEED ............................................................................ 3
3.4 SCHEDULING PROCEDURES .................................................................................................... 3
3.5 ACTION TAKEN IF A POLYP IS IDENTIFIED ON SIGMOIDOSCOPY ............................................... 3
4.0 UNMET NEED FOR SCREENING AND FOLLOW-UP PROCEDURES .................... 3
4.1 DEVELOPMENT OF THE FORECASTING MODEL ....................................................................... 3
4.1.1 Population estimates...................................................................................................... 3
4.1.2 Estimating the unmet need for colorectal cancer screening.......................................... 3
4.1.3 Need for screening procedures in various screening scenarios .................................... 3
4.1.4 Sensitivity analyses ........................................................................................................ 3
4.2 FORECASTING MODEL RESULTS ............................................................................................ 3
4.2.1 Characteristics of the unscreened population ............................................................... 3
4.2.2 Total number of screening and follow-up procedures required .................................... 3
4.2.3 Sensitivity Analyses........................................................................................................ 3
5.0 COMPARISON OF CURRENT CAPACITY AND UNMET NEED............................... 3
5.1 CAPACITY FOR SCREENING AND FOLLOW-UP PROCEDURES .................................................... 3
5.2 COMPARISON OF CAPACITY AND UNMET NEED ....................................................................... 3
5.3 STUDY LIMITATIONS ............................................................................................................. 3
REFERENCES.............................................................................................................................. 3
APPENDIX A – Screening Telephone Call Script.................................................................... A-1
APPENDIX B – Colorado Cover Letter and Survey of Endoscopic Capacity...........................B-1
APPENDIX C – Counties in Colorado Regions.........................................................................C-1
APPENDIX D – Logistic Regression Coefficients.................................................................... D-1
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Colorado Final SECAP report 12/13/06
List of Tables
Page
2-1
2-2
3-1
3-2
3-3
3-4
3-5
3-6
3-7
3-8
3-9
4-1
4-2
4-3
4-4
5-1
5-2
5-3
5-4
5-5
5-6
Number of eligible facilities, by region and survey administration.....................................8
Surveys and response rate, by region and survey administration ........................................8
Percentage of all flexible sigmoidoscopies and colonoscopies performed by
physician specialty for Colorado and the nation................................................................13
Urban/rural and regional breakdown of facilities by practice specialty - Colorado ..........14
Percentage of all flexible sigmoidoscopies and colonoscopies performed, by
physician specialty, by practice specialty for Colorado.....................................................15
Type of lower GI equipment owned, by region.................................................................16
Procedures currently being performed in Colorado and the nation ...................................17
Measures to address increased need for flexible sigmoidoscopy and colonoscopy in
Colorado and the nation .....................................................................................................18
Amount of room time typically scheduled for flexible sigmoidoscopy and
colonoscopy, in Colorado and the nation...........................................................................19
Typical waiting time for various endoscopy procedures for Colorado and the nation......20
Action taken if lesions of various sizes are identified during a screening
sigmoidoscopy in a healthy, average-risk patient ..............................................................21
Socio-demographic characteristics of the average risk population for Colorado (in
thousands) ..........................................................................................................................28
Number of screening and follow-up tests required to immediately satisfy unmet
need for Colorado ..............................................................................................................29
Annual number of screening and follow-up endoscopies required to satisfy unmet
need over multiple years ....................................................................................................31
Sensitivity analyses for Colorado – base case ...................................................................32
Estimated number of practices that provide endoscopies statewide, by regions ...............34
Potential volume, current volume, and unused capacity for flexible sigmoidoscopy
and colonoscopy, by region – annual number of procedures.............................................35
Comparison of unmet need and unused capacity, base case and options ..........................37
Comparison of unmet need and unused capacity for flexible sigmoidoscopy and
colonoscopy, by region – base case ...................................................................................38
Difference between unused capacity and unmet need over multiple years, base case
and options .........................................................................................................................39
Difference between unused capacity and unmet need over multiple years, by region
– base case..........................................................................................................................40
List of Figures
Page
2-1
4-1
Colorado Regions.................................................................................................................7
Estimated number of people needing CRC screening and follow-up................................22
iii
Colorado Final SECAP report 12/13/06
1.0 Introduction
This report represents the final report of the Colorado Survey of Endoscopic Capacity (Colorado
SECAP)—a study which was conducted to assess the current capacity of the Colorado health
care system to conduct colorectal cancer (CRC) screening and follow-up examinations for
average-risk persons 50 years of age and older. Data for the study were obtained from a survey
sent to all health care facilities known to have purchased flexible sigmoidoscopes and
colonoscopes between 1996 and 2003 based on lists provided by major endoscopic equipment
manufacturers. The survey obtained information regarding the number of colorectal cancer
screening and follow-up examinations currently being performed, as well as the maximum
number of screening and follow-up examinations that could be performed in the event of
widespread screening. The study then compared the actual numbers of endoscopic procedures
currently being performed and the maximum number currently possible with the number of
procedures needed for the eligible population, based on the demographic composition of the
population of Colorado and current rates of screening. Estimates are provided for each of seven
sub-state regions, as well as for the state overall. The results of the study provide valuable
information to determine whether or not the capacity can meet the potential need for colorectal
cancer screening and follow-up procedures.
In this report we summarize the methods and findings from the study. The study methods—the
objectives of the study, survey design and administration, and statistical techniques—are
described in Section 2. In Section 3 we estimate the current capacity for colorectal cancer
screening and follow-up examinations. This includes a discussion of the number of colorectal
cancer screening and follow-up procedures that are currently being performed, the maximum
number of procedures that could be performed in the event of widespread screening and the
characteristics of the medical facilities and providers that currently perform colorectal cancer
screening and follow-up examinations. In Section 4 we estimate the size of the unscreened
average-risk population 50 years of age and older and the tests needed to screen them. Finally,
in Section 5 we compare the potential volume with the unmet need for colorectal cancer
screening and follow-up examinations in order to assess the capacity of the health care system to
provide the necessary colorectal cancer screening and follow-up examinations.
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Colorado Final SECAP report 12/13/06
2.0 Study Methods
2.1 Objectives of the Study
The primary goal of the study was to determine the capacity of the Colorado health care system
to provide endoscopic colorectal cancer screening and follow-up to all appropriate persons.
Specifically, the objectives of the study were to:
•
Describe the health care provider and facility characteristics of those providers who are
performing screening and follow-up examinations;
•
Estimate the number of colorectal cancer screening and follow-up examinations currently
being performed by facilities that own sigmoidoscopes and colonoscopes and the
maximum number of screening and follow-up examinations that could be performed in
the event of widespread screening;
•
Determine the unmet need for colorectal cancer screening and follow-up examinations
among average risk individuals 50 years of age and older; and
•
For the state overall, as well as for seven sub-state regions, compare the number of
procedures that could be performed with the need for colorectal cancer screening and
follow-up examinations in order to assess the current capacity of the health care system to
provide the necessary colorectal cancer screening and follow-up examinations.
To obtain information on the current capacity of Colorado facilities to conduct colorectal cancer
screening and follow-up examinations, a survey was administered to all health care facilities
known to have purchased flexible sigmoidoscopes and colonoscopes between 1996 and 2003.
This included single-specialty and multi-specialty physician practices, single-specialty and multispecialty ambulatory endoscopy/surgery centers, hospitals, medical clinics, and managed care
organizations. In addition, to estimate the unmet need for colorectal cancer screening and
follow-up examinations, a forecasting model was developed and used to: (1) estimate the number
of average-risk people 50 years of age and older who have not been screened for colorectal
cancer; (2) describe the socio-demographic characteristics of the unscreened population; and (3)
estimate the annual number of procedures required to satisfy the unmet need for endoscopic
colorectal cancer screening and follow-up tests.
2.2 Survey Design and Administration
All facilities in Colorado that are known to have purchased lower gastrointestinal (GI)
endoscopic equipment between 1996 and 2003 were surveyed to obtain information regarding
the number of screening and follow-up procedures that are currently being performed, the
maximum number of procedures that could be performed in the event of widespread screening,
and the characteristics of the practices and the providers performing screening and follow-up
procedures (including non-physician providers). Data were obtained in both a national and state
survey:
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Colorado Final SECAP report 12/13/06
•
National Survey of Endoscopic Capacity. In the spring of 2002, the national Survey of
Endoscopic Capacity was administered to a stratified random sample of 1,800 facilities
throughout the U.S. that perform lower GI endoscopic procedures. A total of 15
Colorado facilities completed mail surveys as part of the national Survey of Endoscopic
Capacity.
•
Colorado Survey of Endoscopic Capacity. In the fall of 2004, all Colorado facilities
that were not surveyed in the national survey were contacted and asked to participate in
the Colorado State Survey of Endoscopic Capacity. A total of 85 Colorado facilities
completed mail surveys as part of the Colorado Survey of Endoscopic Capacity.
All facilities that perform endoscopy were identified based upon data provided by endoscopic
equipment manufacturers and an ambulatory surgery center management company. Facilities
were contacted by telephone to verify their eligibility and to obtain the name and address of the
person in charge of endoscopy at the facility. The survey was sent to the physician identified in
the screening telephone call using established survey administration procedures to maximize
response rates among busy physicians.
In this section we provide a detailed description of the survey design and administration. In
particular, we describe (1) development of the survey instrument, (2) identification of the eligible
facilities that perform endoscopy, (3) data collection procedures, (4) region definitions, and (5)
survey response rate.
2.2.1 Development of the survey instrument
Two survey instruments were developed for use in the study: a telephone screening questionnaire
and a self-administered survey. The purpose of the screening questionnaire was to confirm that
the facility was eligible for inclusion in the study (lower endoscopy being performed for
colorectal cancer screening in adults) and to obtain the name and address of the physician in
charge of endoscopy at the facility. The self-administered questionnaire was then sent by
Federal Express to the physician identified during the telephone screening call. The selfadministered survey was designed to obtain information regarding:
•
•
•
•
•
•
•
The numbers of flexible sigmoidoscopies and colonoscopies currently being performed
and the types of providers performing the procedures (including the numbers of
procedures performed by non-physician endoscopists)
The maximum numbers of flexible sigmoidoscopies and colonoscopies that could be
performed with no other investment of resources
Step(s) that would be taken if the need for screening flexible sigmoidoscopy and
colonoscopy were to exceed their current capacity to perform these procedures
Number and type of endoscopes owned by the facility
Percentage of procedures that are for screening
Percentage of procedures that are incomplete
Room time for flexible sigmoidoscopies and colonoscopies
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Colorado Final SECAP report 12/13/06
•
•
Waiting times for flexible sigmoidoscopy and colonoscopy appointments
Action taken if polyps are found on sigmoidoscopy (for various sizes of polyps)
In developing the questionnaire used in the national survey, input was sought from providers
similar to the individuals who would be selected to participate in the survey. The survey
instrument was also pre-tested at nine facilities that perform colorectal cancer screening and
follow-up examinations. In addition to pre-testing the mail survey, the telephone screening call
was also pre-tested and was found to be a successful way of identifying the appropriate
respondent for the mail survey, the person who would be most able to describe endoscopy
volume for the entire practice, even in large hospital settings.
Following the pretest, the screening call script was shortened and minor revisions were made to
the mail survey questionnaire to clarify confusing terminology (e.g., health care provider, nonphysician provider, follow-up colonoscopy). Questions were also reordered to improve skip
logic. The final SECAP questionnaire, which was approved by OMB and the CDC and Battelle
IRBs, was used to survey approximately 1,800 facilities in the National SECAP study.
Following analysis of the national SECAP data, a few modifications were made to the instrument
for the State SECAP study. For example, the classification of facility type was simplified and
questions regarding reimbursement for procedures were deleted. Modifications to the survey
instrument for the State SECAP were minimal, allowing us to combine data from the two
surveys for analysis.
2.2.2 Identification of the eligible facilities that perform endoscopy
All Colorado medical practice sites that perform colorectal cancer screening and follow-up in
adults using flexible endoscopic equipment (sigmoidoscopes and colonoscopes) were considered
to be eligible for participation in the study. The names and addresses of these medical practice
sites were obtained from endoscopic equipment manufacturers and a practice management
company for ambulatory surgery centers. Four major endoscopic equipment manufacturers,
Olympus America, Inc., Fujinon, Inc., Pentax Precision Instrument Corporation, and Welch
Allyn, Inc. provided names and addresses of facilities purchasing endoscopic equipment from
January 1, 1996 through December 31, 2003. (Welch Allyn, Inc. was no longer in the business
of distributing sigmoidoscopes and colonoscopes after December 2000). In addition, AmSurg, a
practice management company for ambulatory surgery centers, provided a list of single- and
multi-specialty ambulatory endoscopy/surgery centers in the United States as of December 2000
and December 2003.
Preparation of the state SECAP facility file involved standardizing the files, merging the files,
and removing duplicates or ineligible cases (e.g., veterinarians, pediatric hospitals, moving and
storage companies).
2.2.3 Data collection procedures
The target population for the survey included all facility settings where flexible sigmoidoscopy
or colonoscopy is used to detect colorectal cancer in adults.
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Colorado Final SECAP report 12/13/06
Telephone screening calls
Current telephone numbers for the facilities were obtained electronically from a phone match
program or by searching Internet phone directories and facility websites. Both the facility
address and name were used to search for phone numbers, to ensure that medical facilities that
changed names or moved were not missed. Facilities that could not be found by either facility
address or name were presumed to be out of business.
A telephone screening call was made to (1) verify that the facility was eligible for inclusion in
the study, and (2) to obtain the name and address of the physician in charge of endoscopy. Not
all facilities that purchased equipment were still performing lower endoscopy at the time of the
screening call. To insure that new facilities opening since 2003 were not missed, those facilities
no longer performing lower endoscopy were asked if the doctors at the facility now perform the
procedures somewhere else, and if so, the name and address of the other location. These new
locations were crosschecked against the facility file, and if determined to be unique, added to the
facility file as new cases. As a result, one physician practice was added to the original Colorado
facility file.
The script of the telephone screening call is provided in Appendix A. The telephone
interviewers used a computer-assisted version of this script that prompted them to ask for
additional information depending upon the previously recorded answers. For example, the script
varied depending upon whether the facility was a hospital, ambulatory surgery center, or
physician office.
In hospital settings, endoscopic procedures are sometimes performed in a number of different
departments within the hospital (as well as at satellite clinics). Therefore, in contacting
hospitals, we directed our telephone screening call to the charge nurse in the endoscopy suite,
assuming he/she would be familiar with all sites in the hospital. The charge nurse was asked to
identify all locations within the hospital and all satellite clinics where sigmoidoscopies and
colonoscopies are performed. These additional departments and satellite clinics were also crosschecked against the respondent facility file and added if they were unique. These new
departments and satellite clinics were then called and the name and address of the physician in
charge of endoscopy in that department or clinic was obtained. As a result, one hospital
department was added to the original Colorado facility file.
Conduct of the mail survey
Following the initial screening call, a survey packet was sent to the physician identified during
the call. The packet included (1) the survey questionnaire with an ID number, (2) a personal
cover letter, signed by the Director of the Division of Cancer Prevention and Control at CDC,
emphasizing the importance of the study, (3) a postage-paid return envelope addressed to
Battelle, and (4) a payment of $40 as an incentive for the respondent’s participation in the study.
The letter provided the name and telephone number of the Battelle Task Leader to call with
questions about the study. The letter also included the name and telephone number of a person
to call with questions regarding Human Subjects protection. The survey packet was sent via
Federal Express. The cover letter and survey questionnaire are provided in Appendix B.
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Colorado Final SECAP report 12/13/06
Follow-up procedures
Within two weeks of the initial mailing, a thank-you/reminder postcard was sent to each
respondent to encourage survey completion. The postcard included a toll-free number to call if
the respondent had any questions regarding the survey or needed to have another copy of the
survey mailed. Two weeks after mailing the postcard reminder, a telephone call was placed to
respondents who had not returned a completed questionnaire. This call served as a reminder, and
allowed the opportunity to answer any questions that were delaying completion of the survey. A
second telephone call was made when a completed survey was not received within two weeks
following the first follow-up telephone call. A third (and final) telephone call was made when a
completed survey was not received within two weeks following the second follow-up telephone
call.1 When each completed survey was received, a thank you letter was sent to the respondent
acknowledging participation in the study.
Tracking system
A management information system developed for the National SECAP study (and modified for
the Colorado SECAP study) was used to monitor data collection activities. The database stored
all background data known about each respondent. In addition, the database contained the dates
of screening and follow-up telephone calls, the dates that questionnaires and other survey
materials were mailed, and the dates that completed questionnaires were received. Mailing
labels and personalized letters were generated from this system. Follow-up reminder dates were
computed by the tracking system to ensure timely mailing of necessary follow-up materials and
reminder phone calls. The management information system was also used to generate weekly
reports summarizing the status of the data collection activity.
2.2.4 Region Definitions
In addition to estimating the current capacity and unmet need for colorectal cancer screening and
follow-up examinations at the state level, we also compared current capacity and unmet need by
the regions of the state as shown in Figure 2-1. The number of eligible facilities in each of the
regions is listed in Table 2-1. Appendix C provides a list of the specific counties that are
included in each of the seven regions.
1
Follow-up for the facilities surveyed in the national SECAP was done at three-week, rather than two-week,
intervals.
6
Colorado Final SECAP report 12/13/06
Figure 2-1: Colorado Regions
7
Colorado Final SECAP report 12/13/06
Table 2-1
Number of eligible facilities, by region and survey administration
National SECAP
2002
Colorado SECAP
2005
Total
10
41
51
Southwest
1
8
9
Eastern Plains
2
9
11
South Central Mountain
1
5
6
Northwest
2
10
12
El Paso/Pueblo
4
10
14
Larimer/Weld
2
11
13
22
94
116
Region
Denver Metro
Total
2.2.5 Survey response rate
Of the 116 Colorado facilities that were identified as eligible for inclusion in the study, a total of
100 facilities (86.2%) returned completed questionnaires. The numbers of surveys received and
the response rates achieved in the national and Colorado SECAP are shown in Table 2-2 for the
seven regions. Survey respondents completing the survey on behalf of their facility included 29
(29%) physicians, 56 (56%) nurses and 15 (15%) other.
Table 2-2
Surveys and response rate, by region and survey administration
National SECAP
2002
Region
Denver Metro
Southwest
Eastern Plains
South Central Mountain
Northwest
El Paso/Pueblo
Larimer/Weld
Total
5
Colorado SECAP
2005
Total
(50%)
37
(90%)
1 (100%)
8
(100%)
1
(50%)
8
(89%)
9
(81%)
1 (100%)
4
(80%)
5
(83%)
1
(50%)
9
(90%)
10
(83%)
4 (100%)
9
(90%)
13
(93%)
2 (100%)
10
(91%)
12
(92%)
85
(90%)
15
(68%)
8
42
(82%)
9 (100%)
100 (86%)
Colorado Final SECAP report 12/13/06
2.3 Analysis techniques
The survey data were analyzed using standard univariate and bivariate descriptive statistics (e.g.,
means, frequencies, cross-tabulations). Survey weights were calculated to adjust for nonresponse. The survey weight was calculated as the ratio of the number of eligible facilities in
each of the seven regions to the number of completed surveys in that area. Because the survey
data were weighted to produce state estimates, the data were analyzed using Stata 9.0—a
software package which adjusts for the sample weights (StataCorp, 2005).
In the sections below we describe the procedure used to classify facilities for the analysis and the
procedure used to impute missing data on the key variables.
2.3.1 Definition of practice specialty
Information on the type of facility (e.g., physician practice, ambulatory endoscopy/surgery
center, hospital) was obtained during the telephone screening call, as well as on the mail survey.
However, based on the responses given on the mail survey and after comparing the survey
responses with the information obtained during the screening call, we concluded that the use of
this classification of facility type is problematic. It is not uncommon, for example, for an
ambulatory endoscopy/surgery center to be affiliated with a hospital or a physician practice.
Similarly, lower GI endoscopic procedures often are performed in endoscopy centers or
outpatient clinics affiliated with hospitals. This made it difficult to clearly define facilities as
hospitals versus practices versus ambulatory endoscopy centers. Therefore, instead of
classifying facilities based on the commonly used definition of facility type, we decided instead
to classify facilities based on the specialty of the physicians that perform the flexible
sigmoidoscopy and colonoscopy procedures at the facilities.
For this analysis, facilities were classified as one of four practice types based on the specialty of
the physicians that perform the flexible sigmoidoscopy and colonoscopy procedures at the
facility. These practice specialties include: (1) gastroenterology practices, (2) primary care
practices, (3) surgical practices, and (4) mixed practices. Responses to the mail survey questions
14 and 27 provided data for the following classification:
•
If 75% or more of the procedures are performed by gastroenterologists, the facility was
classified as a gastroenterology practice.
•
If 75% or more of the procedures are performed by family practitioners, general
practitioners and/or internists, the facility was classified as a primary care practice.
•
If 75% or more of the procedures are performed by colorectal and/or general surgeons,
the facility was classified as a surgical practice.
•
If there is no dominant physician specialty or if the dominant physician specialty for
flexible sigmoidoscopy is different than that for colonoscopy, the facility was classified
as a mixed practice.
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Colorado Final SECAP report 12/13/06
Residents, fellows, and non-physician endoscopists were not considered in determining the
practice specialty. If a facility only performs one of the procedures, we classified it based on that
one procedure. If the survey was missing information for one of the procedures, the information
for the other procedure was used to classify the practice site. It should be noted that this
definition of practice type is based on the dominant physician specialty performing lower GI
endoscopic procedures at the facility, rather than the dominant physician specialty for all medical
procedures.
2.3.2 Imputation of missing data
For the estimation of endoscopic capacity, two questions are critical to the analysis. These
critical items included: (1) the number of procedures currently being performed and (2) the
maximum number of procedures that could be performed. A small number of surveys were
missing information regarding the number of procedures currently being performed: one facility
was missing information on the number of flexible sigmoidoscopies currently being performed,
and one facility was missing information on the number of colonoscopies currently being
performed. With respect to the maximum number of procedures that could be performed, among
facilities that perform flexible sigmoidoscopy, 9 were missing the maximum number of
procedures that could be performed. Among facilities that indicated that they perform
colonoscopy, the maximum number of procedures that could be performed was missing for 7
facilities.2
We used two variables to stratify facilities before imputing missing values: (1) whether the
facility was located in a rural or urban area; and (2) practice specialty (gastroenterology, primary
care, surgery, or mixed specialties) performing the procedures at that facility.3 In the National
SECAP, these two variables were found to be closely associated with the number of procedures
performed. Thus, all facilities were stratified into 8 cells based on an urban/rural and practice
specialty classification.4 If a survey indicated that the facility performs flexible sigmoidoscopy
or colonoscopy, but the total number of procedures performed was missing, we imputed an
estimate of current volume. The imputation method, a variation of the hot deck method, is
described below:
1. For the first survey with missing information for current volume, a volume estimate was
randomly selected from among all surveys with reported values from the same cell.
2. The process was repeated for each subsequent survey with missing information
(excluding any surveys that were previously selected to generate imputed values).
2
3
4
If the number of flexible sigmoidoscopies performed each week and the number of colonoscopies performed each
week were both missing, then the case was treated as a refusal.
The type of physicians performing the procedures, or practice specialty, is defined in 2.3.1.
For imputation purposes, we used a dichotomous urban/rural classification based on a ZIP code version of the
rural-urban commuting area (RUCA) coding scheme. To yield a rural-urban dichotomy, RUCA codes 1 (urban
core census tract) to 3 (census tract weakly tied to urban core) were considered to be urban and codes 4 (large
town census tract) to 10 (isolated small rural census tract) were considered to be rural.
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Colorado Final SECAP report 12/13/06
A slightly different procedure was used to impute the maximum number of flexible
sigmoidoscopies or colonoscopies that could be performed:
1. All facilities were stratified into 16 cells based on an urban/rural classification, practice
specialty (gastroenterology, primary care, surgical, or mixed as defined in section 2.3.1)
and the number of procedures currently being performed (e.g., less than the median
number of procedures for the cell, equal to or greater than the median number of
procedures for the cell). These three variables together are highly associated with
potential volume.
2. For the first survey with missing information for potential volume, we randomly selected
a ratio of potential to current volume from among all surveys with valid estimates for
both potential and current volume from the same cell.
3. This ratio was then multiplied by the current volume to provide an imputed value of
potential volume.
4. The process was repeated for each subsequent survey with missing information
(excluding any surveys that were previously selected to generate imputed values).
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Colorado Final SECAP report 12/13/06
3.0 Current Capacity for Colorectal Cancer Screening and Follow-up
In this section we present survey data from Colorado facilities regarding the types of physicians
and practices currently performing lower GI endoscopic procedures, the number of screening and
follow-up procedures that are currently being performed, the maximum number of screening and
follow-up procedures that could be performed, and the measures that facilities would take to
meet an increased need for colorectal screening and follow-up procedures. In addition we
present data on scheduling procedures – room time allocated and waiting time for an
appointment, as well as data on treating polyps. The analyses, which provide information
separately for flexible sigmoidoscopies and colonoscopies, compare Colorado data with national
data from the national SECAP study5. Tables showing differences by the seven regions of
Colorado are presented in a supplemental appendix.
3.1 Characteristics of providers and practices performing endoscopy
The survey asked each facility to report the total number of flexible sigmoidoscopies and
colonoscopies performed by all providers in the practice in a typical week, as well as the
percentage of flexible sigmoidoscopies and colonoscopies performed by various types of
providers. The responses to these questions (weighted for facility non-response) were used to
calculate the percentages of all flexible sigmoidoscopies and colonoscopies performed in
Colorado by provider specialty. The percentages of procedures that are performed by
gastroenterologists, primary care providers (e.g., general practitioner, internist, family
practitioner), and surgeons (e.g., general surgeons, colorectal surgeons) are summarized in Table
3-1. The percentages of procedures that are performed by residents and fellows (with a
supervising physician in attendance), non-physician providers (nurse practitioners, physician
assistants, registered nurses, or licensed practical nurses), and other providers are also shown in
the table.
5
•
Primary care physicians perform 18.2% of flexible sigmoidoscopies and 3.1% of
colonoscopies in Colorado.
•
Gastroenterologists perform 35.9% of the flexible sigmoidoscopies and 85.1% of the
colonoscopies.
•
Surgeons perform 2.8% of the flexible sigmoidoscopies and 10.1% of the colonoscopies.
•
Non-physician endoscopists perform 41.8% of the flexible sigmoidoscopies but do not
perform colonoscopies. One facility accounts for the high percentage of non-physician
endoscopists, in this case nurse practitioners, who perform flexible sigmoidoscopies.
•
Residents and fellows perform less than 5% of the procedures in Colorado.
Between 2000 and 2003, the most recent years of the National Health Interview Survey (NCHS 2004), the use of
colonoscopy (without FOBT) increased from 65% to 80% of the screening tests, while the use of flexible
sigmoidoscopy (without FOBT) declined 35% to 20%. Thus comparisons of state and national data may reflect
the trend between 2002 and 2005 towards greater use of colonoscopy as a screening test, as well as differences
due to population demographics and geography.
12
Colorado Final SECAP report 12/13/06
Table 3-1
Percentage of all flexible sigmoidoscopies and colonoscopies performed
by physician specialty for Colorado and the Nation
(standard errors in parentheses)
Flexible Sigmoidoscopy
Colonoscopy
Colorado 2005
Nation 2002
Colorado
2005
Gastroenterologist
35.9 (6.6)
43.7 (3.3)
85.1 (1.1)
82.5 (1.1)
Primary Care Provider
18.2 (3.5)
24.9 (2.4)
3.1 (0.5)
2.0 (0.3)
General practitioner
4.0 (0.9)
1.8 (0.4)
0.6 (0.2)
0.2 (0.1)
Internist
5.7 (1.4)
13.3 (1.7)
2.2 (0.5)
1.0 (0.2)
Family practitioner
8.5 (1.7)
9.8 (1.2)
0.3 (0.1)
0.8 (0.2)
2.8 (0.6)
20.5 (3.2)
10.1 (0.8)
10.8 (0.8)
General surgeon
2.1 (0.5)
5.1 (0.6)
7.0 (0.4)
7.2 (0.5)
Colorectal surgeon
0.7 (0.2)
15.4 (3.3)
3.2 (0.6)
3.5 (0.5)
Resident with supervising physician in
attendance
1.1 (0.4)
1.4 (0.6)
0.3 (0.1)
0.2 (0.1)
Fellow with supervising physician in
attendance
0.2 (0.1)
2.5 (0.6)
1.3 (0.5)
4.3 (1.2)
41.8 (10.1)
6.1 (2.1)
0.0 (NA)
<0.1(<0.1)
0.0 (NA)
0.7 (0.6)
0.0 (NA)
0.1 (0.1)
79
1002
Surgeon
Non-Physician Endoscopist*
Other
Number of facilities
76
Nation 2002
936
* Non-physician endoscopists include nurse practitioners, physician assistants, registered nurses, and licensed
practical nurses.
We classified the facilities that completed surveys by practice specialty, then weighted the
distribution to account for non-respondents. The estimated number of eligible facilities by
practice specialty in the seven regions is shown in Table 3-2. (Decimal numbers are due to
estimating practice specialty for survey non-respondents). The table also shows the number of
facilities as a percent of the total for Colorado as compared with the national distribution.
We estimate that Colorado has 43 gastroenterology practices, 27 primary care practices, 13
surgical practices, and 33 mixed practices that perform lower GI endoscopy.
13
Colorado Final SECAP report 12/13/06
Table 3-2
Urban/rural and regional breakdown of facilities by practice specialty - Colorado
Gastroenterology
Practices
Primary Care
Practices
Surgical
Practices
Mixed Practices
Total
Urban/rural (Number of Facilities)
Urban
35.9
21.1
1.2
23.6
81.7
Rural
6.8
5.8
12.1
9.6
34.3
21.9
14.6
0
14.6
51
Southwest
2
1
6
0
9
Eastern Plains
0
2.4
3.7
4.9
11
South Central
Mountain
3.6
1.2
0
1.2
6
Northwest
1.2
1.2
3.6
6
12
El Paso/
Pueblo
9.7
0
0
4.3
14
Larimer/ Weld
4.3
6.5
0
2.2
13
26.9
13.3
33.1
116
Region (Number of Facilities)
Denver Metro
Total (Number of Facilities)
42.7
Percentage of Total Facilities
Colorado 2005
36.8
23.2
11.4
28.6
100.0
Nation 2002
46.3
20.0
12.0
21.6
100.0
The percentage of all flexible sigmoidoscopies and colonoscopies performed by physician and
practice specialty are given in Table 3-3. This table shows that the classification of practice
specialty accurately describes the type of physicians who are performing the procedures, except
for the gastroenterology facilities where most of the flexible sigmoidoscopies are performed by
non-physician specialists. In gastroenterology practices, 98.4% of colonoscopies are performed
by gastroenterologists. In primary care practices, primary care physicians – general
practitioners, internists, or family practitioners – perform 100% of both flexible sigmoidoscopies
and colonoscopies. In surgical practices, 99.7% of the flexible sigmoidoscopies and 99.4% of
the colonoscopies are performed by surgeons. In surgical practices, general surgeons perform
over 99% of the flexible sigmoidoscopies and colonoscopies. In mixed practices, there is no
dominant physician specialty performing the procedures; flexible sigmoidoscopies are done by
primary care physicians, non-physician endoscopists, gastroenterologists, and surgeons. In
mixed practices gastroenterologists perform 71.3% of the colonoscopies with surgeons (both
general and colorectal) performing most of the rest.
14
Colorado Final SECAP report 12/13/06
Table 3-3
Percentage of all flexible sigmoidoscopies and colonoscopies performed, by physician
specialty, by practice specialty for Colorado
(standard errors in parentheses)
Gastroenterology
Practices
Primary Care
Practices
Surgical
Practices
Mixed Practices
44.8 (10.6)
0.0 (NA)
0.0 (NA)
16.4 (1.0)
0.3 (0.1)
54.9 (4.5)
<0.1 (<0.1)
0.3 (0.1)
24.8 (3.0)
Flexible sigmoidoscopy
Gastroenterologist
Primary Care Provider
0.4
(0.2)
General practitioner
0.3
(0.1)
Internist
0.1 (<0.1)
32.1
(6.9)
0.0 (NA)
17.3 (2.6)
<0.1 (<0.1)
67.9
(6.9)
0.0 (NA)
12.8 (2.6)
Family practitioner
100.0 (0.0)
0.2 (<0.1)
0.0 (NA)
99.7 (0.1)
13.1 (2.7)
0.2 (<0.1)
0.0 (NA)
99.7 (0.1)
8.2 (2.6)
<0.1 (<0.1)
0.0 (NA)
0.0 (NA)
4.9 (1.0)
Resident
0.1 (<0.1)
0.0 (NA)
0.0 (NA)
6.7 (2.2)
Fellow
0.0 (NA)
0.0 (NA)
0.0 (NA)
1.4 (0.5)
54.5 (10.8)
0.0 (NA)
0.0 (NA)
7.5 (2.9)
0.0 (NA)
0.0 (NA)
0.0 (NA)
0.0 (NA)
0.0 (NA)
0.0 (NA)
71.3 (2.3)
Surgeon
General surgeon
Colorectal surgeon
Non-physician endoscopist
Other
Colonoscopy
Gastroenterologist
98.4
(0.3)
Primary Care Provider
0.0 (NA)
100.0 (NA)
0.6 (0.1)
8.9 (1.6)
General practitioner
0.0 (NA)
37.8 (12.2)
0.4 (<0.1)
1.6 (0.6)
Internist
0.0 (NA)
0.0 (NA)
0.2 (0.1)
7.2 (1.5)
Family practitioner
0.0 (NA)
62.2 (12.2)
0.0 (NA)
0.1 (<0.1)
Surgeon
General surgeon
Colorectal surgeon
0.7
(0.1)
0.0 (NA)
99.4 (0.1)
16.4 (1.7)
0.6
(0.1)
0.0 (NA)
99.4 (0.1)
5.9 (0.7)
<0.1 (<0.1)
0.0 (NA)
0.0 (NA)
10.5 (1.8)
Resident
0.5
(0.2)
0.0 (NA)
0.0 (NA)
0.0 (NA)
Fellow
0.5
(0.2)
0.0 (NA)
0.0 (NA)
3.4 (1.4)
Non-physician endoscopist
0.0 (NA)
0.0 (NA)
0.0 (NA)
0.0 (NA)
Other
0.0 (NA)
0.0 (NA)
0.0 (NA)
0.0 (NA)
The survey asked the respondent to report the number of different types of sigmoidoscopes and
colonoscopes owned by the practice. The mean and total number of colonoscopes and flexible
sigmoidoscopes (e.g., 60 cm sigmoidoscopes, 30 cm sigmoidoscopes, and other types of lower
endoscopes) are shown by region in Table 3-4.
15
Colorado Final SECAP report 12/13/06
Table 3-4
Type of lower GI equipment owned, by region
(standard errors in parentheses)
Colonoscopes
Flexible
sigmoidoscopes
60cm
Flexible
sigmoidoscopes
30cm
11.2 (1.5)
1.2 (0.3)
0.2 (<0.1)
0.2 (<0.1)
Southwest
3.1 (0.0)
0.0 (NA)
0.0 (NA)
0.0 (NA)
Eastern Plains
1.8 (0.2)
0.3 (0.1)
0.3
0.3 (0.1)
South Central Mountain
5.8 (0.6)
1.0 (0.2)
0.0 (NA)
0.0 (NA)
Northwest
3.2 (0.5)
0.2 (0.1)
0.0 (NA)
0.0 (NA)
El Paso/Pueblo
9.0 (0.3)
1.0 (0.1)
0.2 (<0.1)
0.0 (NA)
Larimer/Weld
6.3 (0.4)
0.0 (NA)
1.0
(0.3)
1.0 (0.3)
572.7(75.0)
61.2(15.9)
10.2
(2.3)
10.2 (2.3)
Southwest
28.1 (0.0)
0.0 (NA)
0.0 (NA)
0.0 (NA)
Eastern Plains
19.6 (1.7)
3.7 (1.1)
3.7
3.7 (1.1)
South Central Mountain
34.5 (3.8)
6.0 (1.0)
0.0 (NA)
0.0 (NA)
Northwest
38.7 (5.8)
2.7 (0.7)
0.0 (NA)
0.0 (NA)
El Paso/Pueblo
126.0 (3.8)
14.0 (2.0)
2.5
(0.7)
0.0 (NA)
Larimer/Weld
81.3 (4.7)
0.0 (NA)
13.0
(3.6)
13.0 (3.6)
Other
Mean per Facility
Denver Metro
(0.1)
Total in Region*
Denver Metro
(1.1)
*Missing values replaced by means
3.2 Number and type of procedures performed
The survey collected information on the number of flexible sigmoidoscopies and colonoscopies
performed per week, the percentage of procedures that are performed for screening, the
percentage of procedures that are incomplete, and the maximum number of procedures that could
be performed per week with no other investment of resources. The responses to these questions
– for Colorado as well as nationally – are summarized in Table 3-5.
•
Of the 116 Colorado facilities that perform lower GI endoscopy, 84.3% perform flexible
sigmoidoscopy and 76.8% perform colonoscopy.
•
Currently Colorado facilities that do flexible sigmoidoscopy perform a mean of 6.2
procedures per week, with approximately half being performed for screening. These
facilities report, on average, that they could do 37.9 flexible sigmoidoscopies per week if
need increased.
16
Colorado Final SECAP report 12/13/06
•
Colorado facilities that perform colonoscopy currently do an average of 39.7
colonoscopies per week, about half for screening purposes. These facilities report that
they could possibly do an average of 77.1 colonoscopies per week, if needed.
•
Colorado facilities could perform six times the number of flexible sigmoidoscopies and
almost twice the number of colonoscopies as they are currently performing.
Table 3-5
Procedures currently being performed in Colorado and the nation
(standard errors in parentheses)
Flexible sigmoidoscopy
Colonoscopy
Colorado 2005
Nation 2002
Colorado 2005
Nation 2002
84.3 (1.2)
82.7 (1.1)
76.8 (1.5)
76.1 (1.2)
Mean number of procedures
performed per week per
facility *
6.2 (1.0)
8.9 (0.6)
39.7 ( 1.1)
49.8 (3.7)
Percent of procedures
performed for screening*
54.0 (1.7)
53.9 (1.2)
55.5 ( 1.1)
46.7 (0.9)
6.5 (0.7)
8.7 (0.5)
3.0 (0.2)
6.7 (0.5)
37.9 (3.1)
30.5 (1.7)
77.1 (2.9)
78.5 (4.0)
Percent of practices that
perform the procedure
Percent of procedures that are
incomplete*
Mean number of procedures
possible per week per
facility*
*Among those practices that perform the procedure
17
Colorado Final SECAP report 12/13/06
3.3 Measures to address increased need
In addition to asking facilities to estimate the maximum number of procedures that they could
perform per week with no other investment of resources, the survey asked what step(s) facilities
would take if the need for screening flexible sigmoidoscopy and colonoscopy were to exceed
their current capacity to perform these procedures. Respondents were instructed to answer ‘yes’
or ‘no’ to a number of response choices. These response choices, along with the percentage of
respondents who answered ‘yes’, are shown in Table 3-6.
Table 3-6
Measures to address increased need for flexible sigmoidoscopy and colonoscopy,
in Colorado and the nation
(standard errors in parentheses)
Flexible Sigmoidoscopy
Colonoscopy
Colorado 2005
Nation 2002
Colorado 2005
Nation 2002
Increase proportion of work day
allocated to procedures
60.0 (2.0)
67.6 (1.5)
73.8 (1.9)
78.0 (1.4)
Increase physician staff
27.2 (1.9)
30.0 (1.5)
50.5 (2.0)
55.8 (1.6)
Increase nursing staff to assist with
procedures
53.8 (2.2)
53.2 (1.6)
82.4 (1.4)
76.0 (1.4)
Increase/hire non-physician
endoscopists to do procedures
13.7 (1.5)
15.7 (1.2)
5.1 (0.9)
5.3 (0.8)
Establish a larger screening
unit/more procedure rooms
27.9 (2.0)
39.9 (1.6)
44.9 (2.1)
63.9 (1.6)
Purchase more equipment
60.0 (2.1)
61.9 (1.6)
72.5 (2.0)
74.6 (1.5)
Refer patient to other practices
27.6 (1.9)
24.4 (1.4)
11.9 (1.5)
14.3 (1.2)
5.0 (1.0)
8.4 (0.9)
3.9 (0.9)
4.5 (0.7)
Other
•
In order to meet increased need for flexible sigmoidoscopies sixty percent of the facilities
in Colorado report that they would increase the proportion of the work day allocated to
procedures and purchase more equipment. About half of Colorado facilities report they
would increase nursing staff to assist with procedures in response to increased need for
flexible sigmoidoscopies.
•
To increase capacity to perform colonoscopies, facilities in Colorado were most likely to
report that they would increase nursing staff, increase the proportion of the work day
allocated to procedures, and purchase more equipment. In addition, approximately half
of the facilities indicated that they would increase physician staff and establish more
procedure rooms if the demand for colonoscopies were to exceed their capacity to
provide the procedure.
18
Colorado Final SECAP report 12/13/06
•
Hiring non-physician endoscopists and referring patients to other practices are options
chosen for flexible sigmoidoscopy more than for colonoscopy. Even for flexible
sigmoidoscopy, only about 14% of Colorado facilities would hire non-physician
endoscopists.
3.4 Scheduling procedures
The survey collected information about the room time typically scheduled for each procedure
and the typical waiting time for an appointment. The waiting time for an appointment reflects
the current capacity to conduct colorectal cancer screening in a timely manner. The percentage
of respondents in Colorado and the nation choosing each response category are shown in Tables
3-7 and 3-8.
•
As shown in Table 3-7, most facilities in Colorado schedule less than 30 minutes for a
flexible sigmoidoscopy, and schedule 30-45 minutes for a colonoscopy.
•
As shown in Table 3-8, more than 80% of Colorado facilities are able to schedule patients
for flexible sigmoidoscopy within a month, and no facilities report that patients wait more
than 3 months. For colonoscopy, 68% of the facilities are able to schedule patients
within a month. Less than 3% of Colorado facilities report that patients wait more than 3
months for a colonoscopy.
Table 3-7
Amount of room time typically scheduled for flexible sigmoidoscopy and colonoscopy, in
Colorado and the nation
(standard errors in parentheses)
Flexible Sigmoidoscopy
Colonoscopy
Colorado 2005
Nation 2002
Colorado 2005
Nation 2002
Less than 30 minutes
64.7 (2.0)
61.5 (1.6)
15.7 (1.5)
4.1 (0.6)
30 - 45 minutes
31.5 (1.9)
36.0 (1.6)
68.0 (2.0)
72.2 (1.5)
3.8 (0.9)
2.5 (0.5)
16.4 (1.6)
23.8 (1.4)
More than 45 minutes
*Among those practices that perform the procedure
19
Colorado Final SECAP report 12/13/06
Table 3-8
Typical waiting time for various endoscopy procedures
for Colorado and the nation
(standard errors in parentheses)
Colorado
2005
Nation
2002
Screening flexible sigmoidoscopy*
Within one month
83.5 (1.6)
73.1 (1.4)
1 – 3 months
16.5 (1.6)
23.0 (1.4)
4 – 6 months
0.0 (NA)
2.6 (0.5)
More than 6 months
0.0 (NA)
1.3 (0.4)
Screening colonoscopy*
Within one month
68.0 (1.9)
66.9 (1.5)
1 – 3 months
29.2 (1.9)
28.1 (1.5)
4 – 6 months
1.4 (0.6)
3.6 (0.6)
More than 6 months
1.4 (0.6)
1.3 (0.4)
Follow-up colonoscopy in original practice*
Within one month
93.1 (1.2)
89.5 (1.0)
1 – 3 months
6.9 (1.2)
10.0 (1.0)
4 – 6 months
0.0 (NA)
0.6 (0.2)
More than 6 months
0.0 (NA)
0.0 (NA)
Follow-up colonoscopy in referral site**
Within one month
70.9 (2.8)
72.5 (2.1)
1 – 3 months
26.7 (2.7)
25.0 (2.0)
4 – 6 months
2.5 (1.0)
2.4 (0.7)
More than 6 months
0.0 (NA)
0.1 (0.1)
Do not refer
45.3 (2.1)
* Among those practices that perform procedure
** Among practices that refer for colonoscopy
20
46.2 (1.7)
Colorado Final SECAP report 12/13/06
3.5 Action taken if a polyp is identified on sigmoidoscopy
For those facilities that perform flexible sigmoidoscopy, respondents were asked whether the
practice routinely performs biopsies during a flexible sigmoidoscopy. About half (52.2%) of the
Colorado facilities perform biopsies during a screening flexible sigmoidoscopy. For those
facilities that perform biopsies, respondents were asked to choose one of the following to
describe what action they typically take if a lesion is identified: (1) a biopsy would be performed
during the sigmoidoscopy; (2) a colonoscopy with biopsy would be scheduled; (3)
sigmoidoscopy would be concluded and routine colorectal screening would be resumed; or (4)
something else would be done. Respondents were instructed to pick only one response.
Table 3-9 shows the percentage of Colorado facilities choosing each option for those facilities
that report they do biopsies during a screening flexible sigmoidoscopy.
•
For polyps less than 5mm, 82% of Colorado facilities would perform a biopsy during the
sigmoidoscopy.
•
For polyps .5-1cm, 60% of Colorado facilities would perform a biopsy during the
sigmoidoscopy. Most of the remaining facilities (37%) would schedule a colonoscopy
with biopsy.
•
For polyps greater than 1 cm., about half of Colorado facilities (58%) would schedule a
colonoscopy with biopsy. Most of the remaining facilities (39%) would biopsy during
the sigmoidoscopy.
•
For multiple polyps, 62% of Colorado facilities would schedule a colonoscopy with
biopsy, and 32% would biopsy during sigmoidoscopy.
Table 3-9
Action taken if lesions of various sizes are identified during a screening sigmoidoscopy
in a healthy, average-risk patient*
(standard errors in parentheses)
Polyp
< 5 mm
Polyp
0.5 – 1 cm
Polyp
> 1 cm
Multiple polyps
Perform biopsy during
sigmoidoscopy
82.1 (1.8)
60.1 (2.4)
39.0 (3.9)
32.0 (2.4)
Schedule colonoscopy with
biopsy
11.9 (1.5)
36.8 (2.4)
57.7 (4.0)
62.2 (2.4)
Conclude sigmoidoscopy and
resume routine CRC
screening schedule
3.2 (0.8)
0.0 (NA)
0.0 (NA)
2.8 (0.8)
Other
2.8 (0.8)
3.1 (0.8)
3.3 (1.4)
3.0 (3.0)
*Among facilities that perform flexible sigmoidoscopies, 52.2% report that they routinely biopsy.
21
Colorado Final SECAP report 12/13/06
4.0 Unmet Need for Screening and Follow-up Procedures
In this section we describe the forecasting model that was used to estimate the unmet need for
colorectal cancer screening and follow-up examinations. The model (1) estimates the number of
average-risk people 50 years of age and older who have not been screened for colorectal cancer
according to current guidelines; (2) describes the socio-demographic characteristics of the
unscreened population; and (3) estimates the annual number of procedures required to satisfy the
unmet need for endoscopic colorectal cancer screening and follow-up tests. We begin by
describing the methods and data sources used in developing the forecasting model. We conclude
with a summary of the number of colorectal cancer screening and follow-up procedures that are
required to satisfy the current unmet need.
4.1 Development of the forecasting model
A forecasting model—based on the demographic characteristics of the population of Colorado—
was developed and used to estimate the current unmet need for colorectal cancer screening and
follow-up procedures (i.e., the number of people who currently have not been screened for
colorectal cancer according to current guidelines). An overview of the forecasting model is
provided in Figure 4-1.
Population 50+
1.1 million
Average Risk
1.0 million
Increased Risk
102,000
Unscreened
487,000
FOBT only
99,000
FOBT + FSIG
108,000
FSIG only
56,000
Screened
589,000
COLON only
224,000
Follow-up COLON
12,000
IBD
3,000
FOBT only
100,000
FOBT + Endoscopy
155,000
CRC
13,000
Family CRC
86,000
Endoscopy
334,000
Figure 4-1: Estimated number of people needing CRC screening and follow-up
22
Colorado Final SECAP report 12/13/06
The model begins with the number of people 50 years of age and older. The population at
increased risk—those with inflammatory bowel disease (IBD), a history of colorectal cancer, or a
family history of colorectal cancer—was estimated and subtracted from the total number of
people 50 years of age and older to determine the size of the average-risk population. Data from
the Colorado Behavioral Risk Factor Surveillance Survey (BRFSS) were analyzed to estimate
colorectal cancer screening rates among average-risk people 50 years of age and older. These
screening rates were then applied to the average-risk population to estimate the number of
individuals who have been screened according to current guidelines and the number who have
not been screened for colorectal cancer. The data used and the assumptions made in developing
the forecasting model are described below.
4.1.1 Population estimates
The total number of people in Colorado 50 years of age and older in 2004—stratified by gender,
race, region, and age—was obtained from the National Center for Health Statistics (National
Center for Health Statistics, 2005). Insurance status and income level by gender, race, and age
were estimated using data from the March Current Population Surveys for 2004 and 2005 (U.S.
Department of Commerce, 2004, 2005).
To determine the size of the population at average risk for colorectal cancer, we first estimated
the number of individuals at increased risk for colorectal cancer. These include people with
inflammatory bowel disease, a history of colorectal cancer, or a family history of colorectal
cancer. We did not attempt to measure the size of the population currently receiving postpolypectomy surveillance colonoscopies. Sources of information regarding the numbers of
individuals at increased risk for colorectal cancer are described below.
6
•
Inflammatory bowel disease. An estimate of the number of individuals with IBD was
obtained from the National Institute of Diabetes and Digestive and Kidney Diseases
(NIDDK) website.6 We assumed that the prevalence of IBD does not vary by state, age
(among those 20 years of age and older), race/ethnicity or gender, and that the mortality
rate for those with IBD is the same as the general population. We used the national
prevalence rate to estimate the number of individuals age 50 and older in Colorado who
have IBD. Approximately 3,000 persons 50 years of age and older with IBD were thus
estimated to be at increased risk due to IBD.
•
History of colorectal cancer. The Colorado Department of Public Health and
Environment provided prevalence data for colorectal cancer stratified by age, race,
gender and region. Based on this, we estimated that approximately 13,000 persons 50
years of age and older have a history of colorectal cancer.
•
Family history of colorectal cancer. An estimate of the number of individuals with a
family history of colorectal cancer stratified by age, race, ethnicity, and gender was
obtained by analyzing data from the 2000 National Health Interview Survey (NHIS).
Persons with a personal history of colorectal cancer were excluded from analysis. A
person was considered to have a family history of colorectal cancer if he or she had a
NIDDK, http://digestive.niddk.nih.gov/statistics/statistics.htm
23
Colorado Final SECAP report 12/13/06
parent, sibling or child who had been diagnosed with colorectal cancer at any age. These
estimates were divided by the national population count to estimate a prevalence rate for
family history of colorectal cancer. Applying these national prevalence rates to the
Colorado population, we estimated that approximately 86,000 persons 50 years of age
and older have a family history of colorectal cancer.
The population at increased risk—those with IBD, a history of colorectal cancer, or a family
history of colorectal cancer—was subtracted from the total number of people 50 years of age and
older to determine the size of the average-risk population.
4.1.2 Estimating the unmet need for colorectal cancer screening
Information on the characteristics of individuals who have been screened for colorectal cancer
based on current screening guidelines, as reported in the Colorado BRFSS for 2002 and 2004,
were used to estimate the characteristics of persons who have not been screened. Multivariate,
multinomial logistic regression was used to determine the relationship between various sociodemographic characteristics (e.g., age, sex, race, income level, health insurance status, region of
the state) and the probability that an individual has been screened with FOBT in the past year,
endoscopy (flexible sigmoidoscopy, colonoscopy) in the past ten years, both FOBT in the past
year and endoscopy in the past ten years, or none of the above.
Because BRFSS does not distinguish between sigmoidoscopy and colonoscopy use, we included
all endoscopies performed within the past 10 years to fully capture colonoscopy use according to
recommended guidelines. In order to separate our estimates for endoscopy in general into either
sigmoidoscopy or colonoscopy, we assumed that the proportions were the same as the estimates
from the 2003 National Health Interview Survey for average risk people.
To account for the sampling weights in our analysis, we used Stata 9.0 (StataCorp, 2005) for the
logistic regression. The coefficients and standard errors for the logistic regression analysis are
shown in Appendix D.
The logistic regression coefficients were used to estimate the proportion of average-risk
individuals who have been screened according to current guidelines:
•
•
•
FOBT within the past year only,
endoscopy within the past 10 years only, and
FOBT within the past year and endoscopy within the past ten years.
These proportions were used to generate population counts of the number of average-risk people
in Colorado 50 years of age and older that have been screened according to current colorectal
cancer screening guidelines. By subtracting the number of individuals that have been screened
from the total number of average-risk individuals, we produced an estimate of the size of the
Colorado population currently in need of colorectal cancer screening and follow-up procedures.
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Colorado Final SECAP report 12/13/06
4.1.3 Need for screening procedures in various screening scenarios
Next, we estimated the total number and type of procedures required to screen the average-risk
population in need of colorectal cancer screening. We estimated the number of procedures
required for a base case and for four alternative screening scenarios. These are described below:
•
Base case – current patterns. In the base case, the use of screening tests is based on the
current pattern of screening test use. The coefficients of the logistic regression analysis
were applied to the characteristics of the unscreened average-risk population to predict
the numbers of various screening tests (e.g., FOBT, endoscopy only, endoscopy plus
FOBT) that will be required.
•
Option 1 – 100% FOBT. Instead of using demographic characteristics to estimate the
type of screening, this option assumes that all eligible unscreened individuals are
screened with FOBT.
•
Option 2 – FOBT + sigmoidoscopy. This option assumes that all eligible unscreened
individuals are screened with FOBT, and those with a negative FOBT, are further
screened with flexible sigmoidoscopy. Those with a positive FOBT would go on to
diagnostic colonoscopy. For this option demographic characteristics are not used to
estimate the type of screening tests.
•
Option 3 – 100% sigmoidoscopy. This option assumes that all eligible unscreened
individuals are screened with a flexible sigmoidoscopy. This assumption does not use the
demographic characteristics to determine the type of screening tests.
•
Option 4 – 100% colonoscopy. This option assumes that all eligible unscreened
individuals are screened with a colonoscopy. This assumption does not use the
demographic characteristics to determine the type of screening tests.
In addition, we estimated the number of procedures required for the base case and four options
for a hypothetical program that targets low income people (e.g., those less than 250% of the
poverty level) between 50 and 65 years of age, with no health insurance. The same method used
to determine unmet need for the general population was used for this target population.
Need for follow-up procedures in each screening scenario
In the base case and all options, we assumed that all positive FOBT and flexible sigmoidoscopy
screening tests are followed by a diagnostic colonoscopy. To estimate the number of persons
who are likely to require diagnostic follow-up from initial screening tests proposed in each of
these hypothetical programs, we applied positivity rates obtained in trials published in peerreviewed literature (Allison, et al., 1996; Palitz, et al., 1997; Mandel et al., 1993; Levin et al.,
1999; UK Flexible Sigmoidoscopy Screening Trial Investigators, 2002). The positivity rates in
the model for unrehydrated FOBT and sigmoidoscopy are 2.5% and 5%, respectively. For
individuals receiving both FOBT and sigmoidoscopy during a year, we assume a 6.25%
positivity rate. This estimate assumes that half the positive cases identified through FOBT are
not identified by sigmoidoscopy.
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Colorado Final SECAP report 12/13/06
4.1.4 Sensitivity analyses
We performed sensitivity analysis on two important parameters that could not be fully evaluated
in our forecasting model. These include the use of DCBE to screen for colorectal cancer and the
number of follow-up procedures required for post-polypectomy surveillance colonoscopies.
Use of DCBE to screen for colorectal cancer
The 2002 and 2004 BRFSS included questions on the use of FOBT and endoscopy; however,
information on the use of double contrast barium enema (DCBE) as a colorectal cancer screening
test was not included in the BRFSS. The forecasting model base case and options assume that
DCBE is not used for screening. As an alternative assumption, we estimated the number of
procedures needed to screen the unscreened population assuming some screening is currently
being performed with DCBE. It is estimated that 2.4 million DCBEs are performed nationwide
for any indication in one year, a number which is based on a national survey of radiologists
(Klabunde et. al., 2002). If we assume that all of the DCBEs are performed for CRC screening
and DCBE is considered effective as a screening test for five years, then the number of
unscreened people would be reduced by 12 million people nationwide. The proportion of these
12 million people who are average-risk and over age 50 is assumed to be the same as the
proportion of average-risk individuals over age 50 that have been screened with either FOBT
and/or endoscopy. The national proportion of the average risk population over age 50 who had
DCBE was then applied to the number of average risk over age 50 individuals in Colorado to
estimate the reduction in the unscreened population for Colorado due to DCBE.
Number of follow-up procedures required for post-polypectomy surveillance
The frequency with which individuals receive follow-up colonoscopies for post-polypectomy
surveillance has a tremendous impact on the need for lower GI endoscopic procedures. It is not
known the extent to which colonoscopies are currently being utilized for this purpose. The
forecasting model base case and options estimates do not include any surveillance colonoscopies.
As a sensitivity analysis, we assumed that persons requiring post-polypectomy surveillance
colonoscopies following the identification of a polyp on screening colonoscopy would receive a
follow-up colonoscopy at various intervals. These include one-year, three-year, and five-year
intervals. This analysis allows us to assess the effect that frequency of post-polypectomy
surveillance has on the number of follow-up procedures required by the unscreened population.
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Colorado Final SECAP report 12/13/06
4.2 Forecasting Model Results
As shown in Figure 4-1, of the 1.0 million average-risk persons in Colorado 50 years of age and
older, 589,000 people (55%) have been screened with FOBT and/or endoscopy—approximately
334,000 with endoscopy (flexible sigmoidoscopy or colonoscopy) only, 100,000 with FOBT
only, and 155,000 with both FOBT and endoscopy at the intervals specified by current screening
guidelines. The remaining 487,000 people represent the size of the average-risk population
currently unscreened for colorectal cancer.
4.2.1 Characteristics of the unscreened population
The socio-demographic characteristics of the unscreened and screened average-risk persons are
presented in Table 4-1. Approximately half (51%) of the average-risk individuals in need of
colorectal cancer screening are women. Of the 487,000 people, approximately 353,000 (72%)
are less than 65 years old and 134,000 are 65 years of age and older. With respect to income,
326,000 of the individuals who have not been screened have incomes greater than 250% of the
poverty level, while 161,000 (33%) have incomes less than 250% of the poverty level. In terms
of health insurance status, 410,000 of the 487,000 unscreened people have health insurance,
whereas approximately 77,000 (16%) people do not have health insurance coverage. Of the
487,000 people, approximately 41,000 (8%) are aged 50-64, have incomes less than 250% of the
poverty level and have no health insurance.
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Colorado Final SECAP report 12/13/06
Table 4-1
Socio-demographic characteristics of the average risk population for
Colorado*
Unscreened
Population
Screened
Population
Total
Total
Gender
486,756
588,592
1,075,349
Male
237,627
273,981
511,608
Female
249,129
314,611
563,741
White NH
391,515
514,639
906,154
Hispanic
68,452
45,687
114,139
Other
26,789
28,266
55,056
<65 years
352,674
326,981
679,655
>65 years
134,083
261,611
395,694
>250% of Poverty Level
325,677
411,976
737,652
<250% of Poverty Level
161,080
176,617
337,696
Yes
409,729
561,599
971,329
No
77,027
26,993
104,020
254,461
324,396
578,857
Southwest
33,982
30,719
64,701
Eastern Plains
22,975
20,562
43,537
South Central Mountain
22,082
22,688
44,771
Northwest
35,831
41,479
77,310
El Paso/Pueblo
71,597
88,395
159,992
Larimer/Weld
45,828
60,353
106,181
Race/Ethnicity
Age
Family Income
Health Insurance
Region
Denver Metro
Age 50-64, <250% of Federal Poverty Level, No Health Insurance
40,652
12,443
53,095
* People ages 50 or older excluding those with family history of CRC, personal history of CRC or
inflammatory bowel disease.
28
Colorado Final SECAP report 12/13/06
4.2.2 Total number of screening and follow-up procedures required
The total numbers of colorectal cancer screening and follow-up procedures required to satisfy the
unmet need—for the base case and the four screening options—are shown in Table 4-2. The
shaded boxes of Figure 4-1 also show the total number of procedures for the base case. Based on
current screening patterns (the base case), approximately 207,000 FOBTs, 164,000 flexible
sigmoidoscopies, and 224,000 screening colonoscopies are required. In addition, based on
reported positivity rates for the various screening tests, approximately 12,000 diagnostic
colonoscopies are required for the base case estimate.
Table 4-2
Number of screening and follow-up tests to
Immediately satisfy unmet need for Colorado
Flexible
Sigmoidoscopy
FOBT
Screening
Colonoscopy
Follow-up
Colonoscopy
Newly
Screened
Total
Colonoscopy
Total
Endoscopy
Colorado average-risk population, 50 years or older
Base Case
Current
patterns
206,883
164,379
223,898
11,934
235,833
400,212
486,756
--
--
12,169
12,169
12,169
486,756
474,587
--
29,966
29,966
504,553
--
486,756
--
24,338
24,338
511,094
--
--
486,756
--
486,756
486,756
Option 1
100% FOBT
Option 2
FOBT +
sigmoidoscopy
Option 3
100%
sigmoidoscopy
Option 4
100%
colonoscopy
Colorado, 50-64 years old, <250% of poverty level, no insurance
Base Case
Current
patterns
18,889
8,941
17,410
858
18,268
27,209
40,652
--
--
1,016
1,016
1,016
40,652
39,635
--
2,503
2,503
42,138
--
40,652
--
2,033
2,033
42,684
--
--
40,652
--
40,652
40,652
Option 1
100% FOBT
Option 2
FOBT +
sigmoidoscopy
Option 3
100%
sigmoidoscopy
Option 4
100%
colonoscopy
FOBT = Fecal Occult Blood Test
Option 2 = FOBT performed first; sigmoidoscopy performed only if FOBT negative
29
Colorado Final SECAP report 12/13/06
Estimates of the number of screening and follow-up procedures that are required to satisfy the
unmet need varies depending upon the screening tests used. If the unscreened population is
screened with FOBT only (Option 1), a total of 12,000 colonoscopies are required to follow-up
positive FOBTs. Option 2—in which people are screened with FOBT first, then if the test is
negative, screened with flexible sigmoidoscopy—will require approximately 475,000 flexible
sigmoidoscopies and 30,000 colonoscopies. Option 3, in which all average-risk people are
screened with flexible sigmoidoscopy, will require that approximately 487,000 flexible
sigmoidoscopies and 24,000 follow-up colonoscopies be performed. If everyone is screened
with colonoscopy, approximately 487,000 colonoscopies would be needed.
The lower half of Table 4-2 focuses on the unscreened population less than 65 years of age, with
no health insurance and with an annual income less than 250% of the poverty level. There are
53,000 low income people ages 50-64 with no health insurance; 41,000 of these people have not
been screened. For all options, the total number of endoscopic procedures needed to screen low
income people without health insurance coverage is approximately 8% of the number of
procedures needed to screen the eligible population at large.
Estimated annual need for screening and follow-up procedures
It is unlikely that a screening program will be able to satisfy the unmet need for colorectal cancer
screening and follow-up procedures in a single year. Therefore, we estimated the annual need
for screening and follow-up procedures based on spreading the procedures over two years, three
years, and four years. Estimates of the annual number of screening and follow-up tests required
to satisfy the unmet need within these different timeframes are shown in Table 4-3 for the base
case, as well as for each of the four screening options.
Based on current screening patterns (the base case), approximately 82,000 flexible
sigmoidoscopies and 118,000 colonoscopies would be necessary each year to satisfy the unmet
need within two years. If these procedures were spread out over four years instead of just two
years, about half as many endoscopies would be necessary each year. The annual number of
screening tests varies by option, with Option 4, all screening done by colonoscopy, requiring
between 122,000 and 243,000 colonoscopies per year, depending upon which timeframe is
chosen.
30
Colorado Final SECAP report 12/13/06
Table 4-3
Annual number of screening and follow-up endoscopies required to satisfy unmet need
over multiple years
2 years
Flexible
Sigmoidoscopy
3 years
Colonoscopy
Flexible
Sigmoidoscopy
4 years
Colonoscopy
Flexible
Sigmoidoscopy
Colonoscopy
Colorado average-risk population, 50 years or older
Base Case
Current patterns
82,189
117,916
54,793
78,611
41,095
58,958
--
6,084
--
4,056
--
3,042
237,294
14,983
158,196
9,989
118,647
7,491
243,378
12,169
162,252
8,113
121,689
6,084
--
243,378
--
162,252
--
121,689
Option 1
100% FOBT
Option 2
FOBT +
sigmoidoscopy
Option 3
100%
sigmoidoscopy
Option 4
100%
colonoscopy
FOBT = Fecal Occult Blood Test
Option 2 = FOBT performed first; sigmoidoscopy performed only if FOBT negative
4.2.3 Sensitivity Analyses
Sensitivity analysis was used to evaluate the effect of two important model parameters on our
estimates of the unmet need for colorectal cancer screening and follow-up procedures for the
base case. These include the use of DCBE to screen for colorectal cancer, and the number of
follow-up procedures required for post-polypectomy surveillance colonoscopies. Results of the
sensitivity analyses are summarized in Table 4-4.
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Colorado Final SECAP report 12/13/06
Table 4-4
Sensitivity analyses for Colorado – base case
Flexible
Sigmoidoscopy
Model Parameters
Colonoscopy
DCBEs
Assume the 24,000 DCBEs estimated for average risk
people are for screening, thereby reducing the
unscreened average risk population over age 50 by
121,000 in Colorado
41,000 fewer
58,000 fewer
Post-polypectomy surveillance *
Assume different intervals for surveillance
Once a year
NA
43,000
Every 3 years
NA
14,000
Every 5 years
NA
9,000
* Annual number of colonoscopy procedures needed by people with clinically significant polyps identified
by screening colonoscopies. Estimates are derived from the base case unscreened population utilizing
colonoscopies.
Use of DCBE to screen for colorectal cancer
Because the BRFSS data did not obtain information on the use of DCBE as a screening test for
colorectal cancer, we were unable to include estimates of the number of people who have been
screened with DCBE in our forecasting model. To examine the potential impact that screening
DCBE has on our estimates of unmet need, we used our national SECAP study estimate of the
number of average-risk people 50 years of age or older who had a DCBE within the past five
years.7 We assumed that these individuals screened with DCBE did not have another screening
test, and that the estimated number for Colorado is proportionate to the population. There are
approximately 1.0 million people in Colorado 50 years or older, about 1.3% of the 82.8 million
people 50 years or older nationwide. Assuming this rate in Colorado, there would be a reduction
of 121,000 unscreened average-risk people in Colorado, thereby reducing the number of
screening flexible sigmoidoscopies required by 41,000 and the number of total colonoscopies
required by 58,000.
Post-polypectomy surveillance
Finally, the number of colonoscopies that are currently being performed to follow-up polyps
detected on colonoscopy is unknown and not counted in the estimates. As a sensitivity analysis,
we assumed that persons requiring post-polypectomy surveillance colonoscopies following the
identification of a polyp on screening colonoscopy receive a follow-up colonoscopy at intervals
ranging from 1 to 5 years. As shown in Table 4-4, the frequency with which individuals receive
7
The national SECAP estimate is based on an estimate of 2.4 million DCBEs performed annually (Klabunde, et.
al., 2002). After adjusting for the number of DCBEs done for individuals at high-risk or under age 50, we
estimated 8.6 million average-risk people were screened with DCBE over the past five years.
32
Colorado Final SECAP report 12/13/06
follow-up colonoscopies for post-polypectomy surveillance has a tremendous impact on the need
for lower GI endoscopic procedures. Post-polypectomy surveillance every year results in an
additional need for 43,000 follow-up colonoscopies among the currently unscreened population.
Extending the interval for post-polypectomy surveillance dramatically reduces the necessary
number of colonoscopies required each year.
33
Colorado Final SECAP report 12/13/06
5.0 Comparison of Current Capacity and Unmet Need
In section 3 we presented data from the Colorado Survey of Endoscopic Capacity regarding the
current capacity of the health care facilities to provide colorectal cancer screening and follow-up
procedures. This included the average number of screening and follow-up procedures that are
currently being performed per week, as well as the maximum number of procedures that could be
performed per week with no other investment of resources. In Section 4 we estimated the need
for colorectal cancer screening and follow-up examinations among average-risk individuals in
Colorado 50 years of age and older who have not been screened for colorectal cancer based upon
current guidelines. In this section we compare the capacity of the Colorado health care system to
perform screening and follow-up endoscopic procedures with the estimate of unmet need to
determine whether or not the current capacity is adequate to meet an increased need for
colorectal cancer screening and follow-up tests.
5.1 Capacity for screening and follow-up procedures
The survey collected information regarding whether or not a facility performs flexible
sigmoidoscopy and colonoscopy. Responses to these questions were used to estimate the total
number of practices that currently perform endoscopies in Colorado. Table 5-1 shows the total
number of practices that perform any endoscopy—as well as the number of practices that
perform flexible sigmoidoscopy and colonoscopy—by region. Of the 116 facilities that perform
endoscopy, 98 facilities (84%) perform flexible sigmoidoscopy and 90 (77%) perform
colonoscopy.
Table 5-1
Estimated number of practices that provide endoscopies statewide,
by region
Flexible
sigmoidoscopy
Region
Denver Metro
Southwest
Eastern Plains
South Central
Mountain
Northwest
El Paso/Pueblo
Larimer/Weld
Total*
Colonoscopy
Any endoscopy
50
35
51
6
8
9
9
10
11
5
6
6
6
10
12
11
14
14
12
7
13
98
90
116
* Numbers may not sum to total due to weighting for nonresponse
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Colorado Final SECAP report 12/13/06
For those facilities that perform flexible sigmoidoscopy and/or colonoscopy, the survey obtained
information regarding the number of procedures performed per week and the maximum number
of procedures that could be performed per week with no other investment of resources. The
responses to these questions were used to estimate the current volume of flexible sigmoidoscopy
and colonoscopy procedures performed in Colorado each year, as well as the potential number of
procedures that could be performed each year. The annual current and potential volumes were
calculated by multiplying the total number of facilities in each region sub-state area in Colorado
that perform the procedure by the weekly mean procedural number per facility by the number of
work weeks per year. We assumed a 46-week working year across all practice specialties and
facility types to account for vacations, professional travel and non-procedural time. The results
of this analysis, by region, are summarized in Table 5-2.
Table 5-2
Potential volume, current volume, and unused capacity for flexible sigmoidoscopy
and colonoscopy, by region – annual number of procedures*
(standard errors in parentheses)
Flexible Sigmoidoscopy
Colonoscopy
Potential
Volume
Current
Volume
Unused
Capacity
Potential
Volume
Current
Volume
Unused
Capacity
106,911
21,927
84,984
173,610
96,354
77,256
(13,034)
(4,693)
(10,622)
(12,818)
(7,465)
(6,829)
6,963
368
6,595
18,676
7,958
10,718
Region
Denver Metro
Southwest**
Eastern
Plains
South
Central
Mountain
Northwest
El Paso/Pueblo
Larimer/Weld
Total
NA
NA
NA
NA
NA
NA
6,972
1,103
5,869
9,108
2,614
6,494
(1,096)
(250)
(867)
(1,194)
(281)
(1,054)
1,932
178
1,754
14,628
3,422
11,206
(412)
(43)
(386)
(4,198)
(609)
(3,930)
3,168
353
2,815
12,365
6,017
6,348
(532)
(89)
(477)
(1,361)
(798)
(741)
37,740
2,626
35,115
66,464
35,370
31,094
(5,169)
(285)
(5,007)
(2,545)
(1,486)
(2,033)
7,076
1,156
5,920
21,179
10,864
10,316
(661)
(74)
(660)
(2,717)
(1,263)
(1,493)
170,762
(14,096)
27,710
(4,710)
143,051
(11,810)
316,030
(14,109)
162,599
(7,786)
153,430
(8,373)
*Assuming 46 work weeks per year
**100% response rate in this region
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Colorado Final SECAP report 12/13/06
Approximately 28,000 flexible sigmoidoscopies and 163,000 colonoscopies are currently being
performed in Colorado each year. With respect to the maximum number of procedures that
could be performed, facilities indicated that approximately 171,000 flexible sigmoidoscopies and
316,000 colonoscopies could be performed each year. The unused capacity is the number of
procedures available to screen the currently unscreened population. There is capacity to perform
approximately 143,000 more flexible sigmoidoscopies and 153,000 more colonoscopies.
5.2 Comparison of capacity and unmet need
As was described in Section 4, we developed a forecasting model—based on the demographic
characteristics of the population in Colorado—and used the model to estimate the current unmet
need for colorectal cancer screening and follow-up procedures. In this section we compare the
current capacity of the Colorado health care system to perform screening and follow-up
endoscopic procedures with the estimate of unmet need to determine whether or not the current
capacity is adequate to meet an increased need for colorectal cancer screening and follow-up
tests.
Estimates of the number of screening and follow-up procedures that are required to satisfy the
unmet need varies depending upon the screening tests used. Therefore, we estimated the number
of procedures required for a base case and for the following four alternative screening scenarios:
•
Base case—the use of screening tests is based on the current pattern of screening test use.
•
Option 1—all unscreened individuals are screened with an FOBT.
•
Option 2—all eligible unscreened individuals are first screened with an FOBT, and if the
results are negative, then screened with a sigmoidoscopy.
•
Option 3—all eligible unscreened individuals are screened with a sigmoidoscopy.
•
Option 4—all eligible unscreened individuals are screened with a colonoscopy.
The upper section of Table 5-3 compares the unused capacity of endoscopic procedures with the
number of colorectal cancer screening and follow-up procedures required by the currently
unscreened population should they opt to be screened within a year. The lower section of Table
5-3 presents the same comparisons for individuals 50-64 years old, without health insurance and
with income less than 250% of the poverty level. Comparisons are made for the base case, as
well as for the four different screening options. The results vary considerably depending upon
the screening options used.
36
Colorado Final SECAP report 12/13/06
Table 5-3
Comparison of unmet need and unused capacity - base case and options*
Flexible Sigmoidoscopy
Unmet Need
Difference Between
Unmet Need and
Unused Capacity*
Colonoscopy**
Unmet Need
Difference Between
Unmet Need and
Unused Capacity*
Colorado average-risk population, 50 years or older
Base Case
Current patterns
164,379
-21,328
235,833
-82,402
--
143,051
12,169
141,261
474,587
-331,536
29,966
123,464
486,756
-343,705
24,338
129,093
--
143,051
486,756
-333,326
Option 1
100% FOBT
Option 2
FOBT + sigmoidoscopy
Option 3
100% sigmoidoscopy
Option 4
100% colonoscopy
Colorado population, 50-64 years old, <250% of poverty level, no insurance
Base Case
Current patterns
8,941
134,110
18,268
135,163
--
143,051
1,016
152,414
39,635
103,416
2,503
150,928
40,652
102,400
2,033
151,398
--
143,051
40,652
112,779
Option 1
100% FOBT
Option 2
FOBT + sigmoidoscopy
Option 3
100% sigmoidoscopy
Option 4
100% colonoscopy
FOBT = Fecal Occult Blood Test
Option 2 = FOBT performed first; sigmoidoscopy performed only if FOBT negative
* Positive values imply excess capacity and negative values imply shortage
**Includes all necessary screening and diagnostic follow-up to positive FOBT and flexible sigmoidoscopy
screening procedures, but does not include surveillance colonoscopies.
•
The base case, reflecting current patterns of screening, results in a shortfall of 21,300
flexible sigmoidoscopies and 82,400 colonoscopies, if all necessary screening procedures
are performed within one year.
•
Current capacity is adequate to meet increased need for Option 1, in which everyone is
screened with FOBT only, and colonoscopies are performed as follow-up to positive
FOBT.
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Colorado Final SECAP report 12/13/06
•
Option 2, in which screening consists of an annual FOBT followed by a sigmoidoscopy if
the FOBT results are negative, shows a shortfall of 332,000 flexible sigmoidoscopies but
not a shortfall of colonoscopies.
•
Option 3, in which everyone receives a screening sigmoidoscopy, results in the greatest
deficit with 344,000 more sigmoidoscopies needed than could be performed in a year.
•
Option 4, in which everyone receives a screening colonoscopy, would require 333,000
more colonoscopies than could be done within a year.
•
The Base Case and all four options are achievable within one year for the special
population of low income individuals without health insurance.
Similar comparisons by region are shown in Table 5-4 for the base case only. If necessary
screening were attempted within a year, shortfalls of flexible sigmoidoscopies would occur in all
regions except the El Paso/Pueblo region. Shortfalls of colonoscopies would occur in all regions
except the South Central Mountain region.
Table 5-4
Comparison of unmet need and unused capacity
for flexible sigmoidoscopy and colonoscopy, by region – base case*
Flexible Sigmoidoscopy
Unmet Need
Difference Between
Unused Capacity and
Unmet Need
Colonoscopy
Unmet Need
Difference Between
Unused Capacity and
Unmet Need
Regions
Denver Metro
94,210
-9,226
113,488
-36,232
Southwest
9,041
-2,447
18,453
-7,735
Eastern Plains
6,881
-1,012
10,157
-3,664
South Central Mountain
4,373
-2,619
11,206
-1
Northwest
11,110
-8,295
19,489
-13,141
El Paso/Pueblo
23,636
11,478
38,602
-7,508
Larimer/Weld
15,127
-9,207
24,437
-14,121
164,379
-21,328
235,833
-82,402
Total
* Positive values imply excess capacity and negative values imply shortage
It is unlikely that all unscreened average-risk persons over age 50 would actually seek screening
within one year, even if the unused capacity were adequate. Table 5-5 shows the difference
between the unmet need and unused capacity for flexible sigmoidoscopy and colonoscopy if the
currently unscreened individuals receive screening and follow-up over two-, three- or four-years,
rather than in a single year. For the base case necessary screening could be achieved within two
years. As shown in Table 5-3, necessary screening could be achieved in one year for Option 1
38
Colorado Final SECAP report 12/13/06
(100% FOBT). In the case of Options 2 and 3, the capacity for colonoscopy is sufficient within
one year, but it would require four years to satisfy unmet need for flexible sigmoidoscopy.
Option 4 (100% colonoscopy) would also require four years to satisfy unmet need.
Table 5-5
Difference between unused capacity and unmet need over multiple years −
base case and options*
2 years
Flexible
Sigmoidoscopy
3 years
Colonoscopy
Flexible
Sigmoidoscopy
4 years
Colonoscopy
Flexible
Sigmoidoscopy
Colonoscopy
Colorado average-risk population, 50 years or older
Base Case
Current patterns
60,862
35,514
88,258
74,819
101,956
94,472
143,051
147,346
143,051
149,374
143,051
150,388
-94,242
138,447
-15,145
143,442
24,404
145,939
-100,327
141,261
-19,201
145,318
21,362
147,346
143,051
-89,948
143,051
-8,822
143,051
31,741
Option 1
100% FOBT
Option 2
FOBT +
sigmoidoscopy
Option 3
100%
sigmoidoscopy
Option 4
100%
colonoscopy
FOBT = Fecal Occult Blood Test
Option 2 = FOBT performed first; sigmoidoscopy performed only if FOBT negative
* Positive values imply excess capacity and negative values imply shortage
Similar comparisons for the base case are shown by region in Table 5-6. In the two-year time
frame, there is adequate capacity for flexible sigmoidoscopy and colonoscopy in the Denver
Metro, Southwest, Eastern Plains, and El Paso/Pueblo regions. For the three-year time frame,
there is adequate capacity in all regions, except the Northwest, where there is a shortage of
flexible sigmoidoscopies and colonoscopies. This shortage disappears in the four-year time
frame.
5.3 Study Limitations
Approximately 28,000 flexible sigmoidoscopies and 163,000 colonoscopies are estimated to
have been performed in Colorado in 2005. Based on the responses to the survey, 171,000
flexible sigmoidoscopies, or six times more than the current flexible sigmoidoscopy volume, and
316,000 colonoscopies, or almost twice the current colonoscopy volume, could be performed
each year.
However, it is important to recognize there are a few limitations to these estimates. First,
although the survey questions on potential volume asked about capacity “with no other
investment of resources”, we can not be certain that respondents answered accordingly. Second,
39
Colorado Final SECAP report 12/13/06
the questions about the maximum number of flexible sigmoidoscopies and colonoscopies possible
were asked independently. Unfortunately, we do not know whether the reported potential
volumes for each procedure are both possible at the same time, or whether an increase in one
procedure would preclude an increase in the other procedure. Given that some of the same
resources – procedure rooms and personnel, for example – are sometimes used for both
procedures, it is unlikely that 171,000 flexible sigmoidoscopies and 316,000 colonoscopies could
be performed in a year.
The forecasting model also has some limitations. The model was designed to estimate the unmet
need of the average risk population, since this represents the largest proportion of the population
in need of colorectal cancer screening and the one we can most clearly define. However, our
estimate of unmet need among the average risk population was based on a static, rather than a
dynamic forecasting model. As a result, the model does not account for the aging of the
population, the number of people moving in and out of the state over time or crossing state
boundaries to be screened, and repeat procedures or post-polypectomy surveillance.
Lastly, because this model is based on current census, cancer prevalence and screening test
prevalence data, results will quickly become outdated, and these estimates will need to be recalculated periodically to maintain an accurate assessment of the size of the unscreened
population.
Table 5-6
Difference between unused capacity and unmet need over multiple years,
by region – base case*
2 years
Flexible
Sigmoidoscopy
3 years
Colonoscopy
Flexible
Sigmoidoscopy
4 years
Colonoscopy
Flexible
Sigmoidoscopy
Colonoscopy
Regions
Denver Metro
37,879
20,512
53,581
39,427
61,431
48,884
Southwest
2,074
1,491
3,581
4,567
4,334
6,105
Eastern Plains
2,429
1,415
3,575
3,108
4,149
3,954
South Central
Mountain
-433
5,602
296
7,470
660
8,404
Northwest
-2,740
-3,397
-888
-148
38
1,476
El Paso/Pueblo
23,296
11,793
27,236
18,226
29,205
21,443
Larimer/Weld
-1,643
-1,903
878
2,170
2,138
4,206
Total
60,862
35,514
88,258
74,819
101,956
94,472
* Positive values imply excess capacity and negative values imply shortage
40
Colorado Final SECAP report 12/13/06
REFERENCES
Allison JE, Tekawa IS, Ransom LJ, and Adrain AL. A comparison of fecal occult-blood tests for
colorectal-cancer screening. N Engl J Med 1996;334:155-159.
Klabunde CN, Jones E, Brown ML, and Davis WW. Colorectal cancer screening with doublecontrast barium enema: a national survey of diagnostic radiologists. AJR Am J Roentgenol
2002;179(6):1419-1427.
Levin TR, Palitz A, Grossman S, Conell C, Finkler L, Ackerson L, Rumore G, and Selby JV.
Predicting advanced proximal colonic neoplasia with screening sigmoidoscopy. JAMA 1999;
281(17):1611-1617.
Lieberman DA, Weiss DG, Bond JH, Ahnen DJ, Garewal H, and Chejfec G. Use of colonoscopy
to screen asymptomatic adults for colorectal cancer. Veterans Affairs Cooperative Study Group
380, 12 NEJM, 2000, 343(3):162-168.
Mandel JS, Bond JH, Church TR, et al. Reducing mortality from colorectal cancer by screening
for fecal occult blood. N Engl J Med 1993;328: 1365-1371.
National Center for Health Statistics. Estimates of the July 1, 2000-July 1, 2004, United States
resident population from the Vintage 2004 postcensal series by year, county, age, sex, race, and
Hispanic origin, prepared under a collaborative arrangement with the U.S. Census Bureau.
Available on the Internet at:
http://www.cdc.gov/nchs/about/major/dvs/popbridge/popbridge.htm. September 9, 2005.
National Center for Health Statistics (2004). Data File Documentation, National Health
Interview Survey, 2003 (machine readable data file and documentation). National Center for
Health Statistics, Centers for Disease Control and Prevention, Hyattsville, Maryland.
NIDDK, NIH Publication No. 99-3873, February 1995. e-text updated: August 1999, accessed
May 8, 2002.
Palitz AM, Selby JV, Grossman S, Finkler LJ, Bevc M, Kehr C, and Conell CA. The Colon
Cancer Prevention Program (CoCaP): rationale, implementation, and preliminary results, HMO
Practice, 1997;11:5-12.
RUCA. Developed by the Health Resources and Service Administration’s Federal Office of
Rural Health Policy, the Department of Agriculture’s Economic Research Service, and the
WWAMI Rural Health Research Center at the University of Washington.
http://www.fammed.washington.edu/wwamirhrc/
SAS statistical analysis software. Cary, NC: SAS Institute, 1996
SEER Cancer Incidence Public-Use Database, 1973-1995. National Cancer Institute. Cancer
Statistics Branch. EPN 343J; MSC 7352: April 1998.
41
Colorado Final SECAP report 12/13/06
StataCorp. 2005 Stata Statistical Software: Release 9.0. College Station, Texas: Stata
Corporation.
UK Flexible Sigmoidoscopy Screening Trial Investigators. Single flexible sigmoidoscopy
screening to prevent colorectal cancer: baseline findings of a UK multicentre randomised trial.
Lancet 2002;359:1291-1300.
U.S. Department of Commerce, Bureau of the Census, Current Population Survey: Annual
Demographic File, 2004, 2005 (computer file). Washington, DC, Ann Arbor, MI:
Interuniversity Consortium for Political and Social Research (distributor).
42
Colorado Final SECAP report 12/13/06
APPENDIX A
SCREENING TELEPHONE CALL SCRIPT
Screening Telephone Call to Identify the Appropriate
Survey Respondent
For each facility to be surveyed, a screening telephone call will be made to (1) confirm that the
facility is eligible for inclusion in the study and (2) obtain the name and address of the individual
who is most knowledgeable about the use of the endoscopic equipment. The questions to be
asked during the screening call will vary by practice setting. The screening survey will be
administered as a computer-assisted telephone interview. As a result, data entry will be
performed as part of the interview process and the skip-logic will be electronic.
The following burden statement will be available to be read to the person responding to the call
if they ask for this information.
Public reporting burden of this collection of information is estimated to average 20-30 minutes per response, including the time
for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and
reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a
collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden
estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC, Project
Clearance Officer, 1600 Clifton Road, MS-24, Atlanta, GA 30333, ATTN: PRA (0920-0539). Do not send the completed form
to this address.
Questions 1-4 will be asked of the individual who answers the phone at the practice site.
1. Hello, my name is (INTERVIEWER NAME). I am calling from the Battelle Centers for
Public Health Research and Evaluation in Seattle, Washington. I am calling on behalf of the
Centers for Disease Control and Prevention and the (Insert state name) Department of Public
Health. They are conducting a statewide survey of facilities that perform endoscopy for the
detection of colorectal cancer. Am I calling (CONFIRM NAME AND ADDRESS)?
IF YES,
CONTINUE WITH QUESTION 2
IF NO,
RECORD NAME AND ADDRESS BELOW BEFORE
CONTINUING WITH QUESTION 2
___________________________
____________________________
____________________________
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Colorado Final SECAP report 12/13/06
2. Does this practice perform flexible sigmoidoscopy or colonoscopy to detect colorectal cancer
in adults?
yes
no
don’t know
If NO to question 2, conclude the interview by saying: “I’m sorry, but our study is
focusing on practice sites that perform colorectal cancer screening in adults. Thank you
very much for your time.”
If DON’T KNOW, ask to speak to someone who might know: “Is there someone else
there who might know? May I speak with him/her?”
3. Are the flexible sigmoidoscopies or colonoscopies performed at this site or somewhere else?
yes, performed at this site
no, performed elsewhere
don’t know
If NO to question 3, conclude the interview by saying: “I’m sorry, but our study is
focusing on practice sites that perform colorectal cancer screening in adults. Thank you
very much for your time.”
If DON’T KNOW, ask to speak to someone who might know: “Is there someone else
there who might know? May I speak with him/her?”
4. Can you please tell me which of the following best describes this practice site?
Private Practice
Ambulatory endoscopy or surgery center
Hospital
IF THE PRACTICE SITE IS A HOSPITAL, THE INTERVIEWER WILL CONTINUE
WITH PART A
IF THE PRACTICE SITE IS AN ANBULATORY ENDOSCOPY/SURGERY CENTER
OR A PRIVATE PRACTICE, THE INTERVIEWER WILL CONTINUE WITH PART B
PART A—TO BE ASKED IF THE PRACTICE SITE IS A HOSPITAL
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Colorado Final SECAP report 12/13/06
Please connect me with the Gastroenterology Department. If the respondent indicates that the
hospital does not have a Gastroenterology Department, ask to be connected to the department
where sigmoidoscopy and/or colonoscopy are performed.
QUESTIONS FOR THE HOSPITAL GASTROENTEROLOGY DEPARTMENT
When the interviewer reaches the Hospital Gastroenterology Department, read the following:
Hello, my name is (INTERVIEWER NAME) and I am calling from the Battelle Centers for
Public Health Research and Evaluation in Seattle, Washington. I am calling on behalf of the
Centers for Disease Control and Prevention and the (Insert state name) Department of Public
Health. They are conducting a statewide survey of facilities that perform endoscopy for the
detection of colorectal cancer. May I please speak with the charge nurse in the endoscopy suite?
If the charge nurse is not available, obtain a name and telephone number of the charge nurse to
call at a later time.
When the interviewer reaches the charge nurse, read the following:
5. Hello, my name is (INTERVIEWER NAME) and I am calling from the Battelle Centers for
Public Health Research and Evaluation in Seattle, Washington. I am calling on behalf of the
Centers for Disease Control and Prevention and the (Insert state name) Department of Public
Health. They are conducting a statewide survey of facilities that perform endoscopy for the
detection of colorectal cancer. Does this hospital perform flexible sigmoidoscopy or
colonoscopy to detect colorectal cancer in adults?
yes
no
If NO to question 5, conclude the interview by saying: “I’m sorry, but our study is
focusing on hospitals that perform colorectal cancer screening in adults. Thank you very
much for your time.”
6. I am trying to identify all the sites within this hospital where sigmoidoscopy and/or
colonoscopy are performed to detect colorectal cancer in adults. As the charge nurse in the
endoscopy suite, I thought you might best be able to help us identify these sites. Can you
please tell me whether or not flexible sigmoidoscopy or colonoscopy are performed in the
following divisions or departments in your hospital? I am only interested in departments that
perform these procedures in adults. (Read and record all that apply)
Gastroenterology department
General surgery department
Colorectal surgery department
Family practice department
General internal medicine department
Operating room
Satellite clinics (list all satellite clinics)
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Colorado Final SECAP report 12/13/06
Other (specify)___________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
7. We would like to send a survey to the person who knows the most about the numbers of
flexible sigmoidoscopies and colonoscopies that are being performed in this department and
who is performing these procedures. Most likely this is the physician who is in charge of
endoscopy at this facility. Can you please tell me the name of that person? If there is no
physician in charge of endoscopy at the facility, ask if there is a nurse or an administrator
who could provide this information. Confirm the spelling of the name, title, and specialty of
the person (to determine if the cover letter and envelope should be addressed to Dr., Mr. or
Ms.).
Name:
__________________________________________
Title:
__________________________________________
Specialty:
__________________________________________
8. What is the Federal Express address and telephone number for Dr./Mr./Ms. (PERSON
IDENTIFIED IN QUESTION 7)? Be sure that the address includes the name of the practice
site (e.g., name of the physician practice, hospital department, clinic, surgical center).
Practice Site:
_________________________________________
Address:
_________________________________________
_________________________________________
City, State, Zip Code:
_________________________________________
Telephone Number:
_________________________________________
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Colorado Final SECAP report 12/13/06
9. Is the mailing address for Dr./Mr./Ms. (PERSON IDENTIFIED IN QUESTION 7) the same
as his/her Federal Express address? If not, what is his/her mailing address?
Address:
_________________________________________
_________________________________________
City, State, Zip Code:
_________________________________________
Conclude the interview with the Gastroenterology Department charge nurse by saying: “That is
all the information I need at the moment. Thank you very much for your time and assistance.
You have been very helpful. Good-bye.”
QUESTIONS FOR OTHER HOSPITAL SITES THAT PERFORM ENDOSCOPY
When the interviewer reaches a hospital department other than the Gastroenterology Department,
read the following:
Hello, my name is (INTERVIEWER NAME) and I am calling from the Battelle Centers for
Public Health Research and Evaluation in Seattle, Washington. I am calling on behalf of the
Centers for Disease Control and Prevention and the (Insert state name) Department of Public
Health. They are conducting a statewide survey of facilities that perform endoscopy for the
detection of colorectal cancer. May I please speak with the charge nurse in the
department/division/clinic? If the charge nurse is not available, obtain a name and telephone
number of the charge nurse to call at a later time.
When the interviewer reaches the charge nurse, read the following:
10. Hello, my name is (INTERVIEWER NAME) and I am calling from the Battelle Centers for
Public Health Research and Evaluation in Seattle, Washington. I am calling on behalf of the
Centers for Disease Control and Prevention and the (Insert state name) Department of Public
Health. They are conducting a statewide survey of facilities that perform endoscopy for the
detection of colorectal cancer. Does [NAME OF THE HOSPITAL
DEPARTMENT/DIVISION/ CLINIC] perform flexible sigmoidoscopy or colonoscopy to
detect colorectal cancer in adults?
yes
no
If NO to question 10, conclude the interview by saying: “I’m sorry, but our study is
focusing on hospital departments that perform colorectal cancer screening in adults.
Thank you very much for your time.”
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Colorado Final SECAP report 12/13/06
11. We would like to send a survey to the person who knows the most about the numbers of
flexible sigmoidoscopies and colonoscopies that are being performed and who are
performing these procedures. Most likely this is the physician who is in charge of endoscopy
at this facility. Can you please tell me the name of that person? If there is no physician in
charge of endoscopy at the facility, ask if there is a nurse or an administrator who could
provide this information. Confirm the spelling of the name, title, and specialty of the person
(to determine if the cover letter and envelope should be addressed to Dr., Mr. or Ms.).
Name:
__________________________________________
Title:
__________________________________________
Specialty:
__________________________________________
12. What is the Federal Express address and telephone number for Dr./Mr./Ms. (PERSON
IDENTIFIED IN QUESTION 11)? Be sure that the address includes the name of the
practice site (e.g., name of the hospital department, outpatient clinic, surgical center).
Practice Site:
_________________________________________
Address:
_________________________________________
_________________________________________
City, State, Zip Code:
_________________________________________
Telephone Number:
_________________________________________
13. Is the mailing address for Dr./Mr./Ms. (PERSON IDENTIFIED IN QUESTION 11) the same
as his/her Federal Express address? If not, what is his/her mailing address?
Address:
_________________________________________
_________________________________________
City, State, Zip Code:
_________________________________________
Conclude the interview with the charge nurse by saying: “That is all the information I need at
the moment. Thank you very much for your time and assistance. You have been very helpful.
Good-bye.”
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Colorado Final SECAP report 12/13/06
PART B—TO BE ASKED IF THE PRACTICE SITE IS AN AMBULATORY
ENDOSCOPY/SURGERY CENTER OR A PRIVATE PRACTICE
14. We would like to send a survey to the person who knows the most about the numbers of
flexible sigmoidoscopies and colonoscopies that are being performed and who is performing
these procedures. Most likely this is the physician who is in charge of endoscopy at this
facility. Can you please tell me the name of that person? If there is no physician in charge of
endoscopy at the facility, ask if there is a nurse or an administrator who could provide this
information. Confirm the spelling of the name, title, and specialty of the person (to determine
if the cover letter and envelope should be addressed to Dr., Mr. or Ms.).
Name:
__________________________________________
Title:
__________________________________________
Specialty:
__________________________________________
15. What is the Federal Express address and telephone number for Dr./Mr./Ms. (PERSON
IDENTIFIED IN QUESTION 14)? Be sure that the address includes the name of the
practice site (e.g., name of the physician practice, clinic, surgical center).
Practice Site:
_________________________________________
Address:
_________________________________________
_________________________________________
City, State, Zip Code:
_________________________________________
Telephone Number:
_________________________________________
16. Is the mailing address for Dr./Mr./Ms. (PERSON IDENTIFIED IN QUESTION 14) the same
as his/her Federal Express address? If not, what is his/her mailing address?
Address:
_________________________________________
_________________________________________
City, State, Zip Code:
_________________________________________
Conclude the interview by saying: “That is all the information I need at the moment. Thank you
very much for your time and assistance. You have been very helpful. Good-bye.”
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Colorado Final SECAP report 12/13/06
APPENDIX B
COLORADO SURVEY OF ENDOSCOPIC CAPACITY
COVER LETTER AND MAIL QUESTIONNAIRE
B-1
Colorado Final SECAP report 12/13/06
,
,
,
Dear :
We are requesting your participation in the Survey of Colorado Endoscopic Capacity (SECAP), a survey
that is being conducted for the Centers for Disease Control and Prevention and the Colorado Department
of Public Health and Environment. The purpose of this research study is to estimate the numbers of
endoscopic procedures currently being performed to detect colorectal cancer and to describe the medical
facilities in which these procedures are being performed. Data will be obtained by surveying medical
practices that own flexible endoscopic equipment. Study results will be used to identify deficits in the
current medical infrastructure for colorectal cancer screening and will provide critical baseline
information for use in planning statewide initiatives to increase screening for colorectal cancer.
Colorectal cancer is the second leading cause of cancer-related deaths in the U.S. Although major
professional organizations now recommend regular screening for colorectal cancer for average risk
persons aged 50 and older, screening rates are unacceptably low. Little information is available
regarding the capacity of the health care system to provide widespread screening and follow-up
examinations.
All facilities in the state of Colorado that are known to own flexible sigmoidoscopes and colonoscopes,
based upon lists provided by major endoscopic equipment manufacturers, are being asked to complete
the survey. You were identified by your practice as the person most knowledgeable about the use of the
endoscopic equipment at your facility. We are asking you to complete the enclosed questionnaire,
requiring approximately 25 minutes of your time. If flexible sigmoidoscopy or colonoscopy is not done
by any physician or non-physician endoscopist at the practice site identified above, or if the procedures
are not done for the purposes of screening for colorectal cancer, please indicate this on the survey cover
and return it in the postage paid envelope.
Please note that since we are surveying all facilities in the state, in completing the survey it is important
that you report only those procedures that are performed at the location identified above. You can return
the survey in the enclosed postage-paid return envelope. The CDC realizes that your time is extremely
B-2
Colorado Final SECAP report 12/13/06
valuable and we have enclosed a $40 reimbursement in appreciation of your time and effort given to the
study.
Your participation in the study is completely voluntary. Data collection will be managed by Battelle,
Center for Public Health Research, a national survey and research organization with extensive
experience in collection of health data. Data will be aggregated; no individual facility information will
be presented in any report. Your responses will be kept private to the extent allowed by law. To protect
your privacy, we will keep the records under a code number rather than by name. Records will be stored
in locked files to which only study staff will have access.
Information linking you to the data you supply will be destroyed after data collection has been
completed. Your name or any other personal identifiers will not appear when we present in oral or
written presentation of study results.
If you have any questions regarding the study, please call Diane Manninen, Ph.D., Task Leader, Battelle,
at 1-800-426-6762. If you have any questions regarding your rights as a study subject, please contact
Margaret Pennybacker, Chairperson of the Battelle Institutional Review Board, at 1-877-810-9530, ext.
500.
Thank you in advance for your time and participation in this important research endeavor.
Sincerely,
Kevin Brady, M.P.H.
Acting Director
Division of Cancer Prevention and Control
National Center for Chronic Disease
Prevention and Health Promotion
B-3
Colorado Final SECAP report 12/13/06
OMB #0920-0590
EXP. DATE: 06/30/2006
CDC Survey of Colorado
Endoscopic Capacity (SECAP)
Conducted for
Centers for Disease Control and Prevention
National Center for Chronic Disease Prevention and Health Promotion
Division of Cancer Prevention and Control
Atlanta, GA
and
Colorado Department of Public Health and Environment
Denver, CO
Public reporting burden of this collection of information is estimated to average 20-30 minutes per response, including the time
for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and
reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a
collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden
estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC, Project
Clearance Officer, 1600 Clifton Road, MS-24, Atlanta, GA 30333, ATTN: PRA (0920-0590). Do not send the completed form
to this address.
B-4
Colorado Final SECAP report 12/13/06
OMB #0920-0590
EXP. DATE: 06/30/2006
CDC Survey of Colorado
Endoscopic Capacity (SECAP)
The Centers for Disease Control and Prevention (CDC) and the Colorado Department of Public Health
and Environment are conducting a research study involving a statewide survey to determine the current
capacity of the Colorado health care system to provide endoscopic colorectal cancer screening and
follow-up examinations to all appropriate persons. The results of the survey will be used to identify
deficits in the current medical infrastructure, as well as to provide critical baseline information for use in
planning state initiatives aimed at increasing colorectal cancer screening.
All information that you provide will be kept private to the extent allowed by law, and CDC does not plan
to disclose identifiable data to anyone but the researchers conducting the study. Responses will be
reported only in summary form along with information from the other facilities that participate in the
survey. No personal identifiers will be included in either oral or written presentation of the study results.
Participation in the study is voluntary. You are subject to no penalty if you choose not to provide all or
any part of the requested information.
If you have any questions regarding the study, please call Diane Manninen, Ph.D., Task Leader, Battelle
at 1-800-426-6762. If you have any questions regarding your rights as a study subject, please contact
Margaret Pennybacker, Chairperson of the Battelle Institutional Review Board, at 1-877-810-9530, ext.
500.
When you have completed the survey, please return it in the enclosed postage-paid envelope to: CDC
SECAP Study Office, Battelle Seattle Research Center, 1100 Dexter Avenue North, Suite 400, Seattle,
WA 98109-3598.
Thank you for your participation in this important study.
Public reporting burden of this collection of information is estimated to average 20-30 minutes per response, including the time
for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and
reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a
collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden
estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC, Project
Clearance Officer, 1600 Clifton Road, MS-24, Atlanta, GA 30333, ATTN: PRA (0920-0590). Do not send the completed form
to this address.
B-5
Colorado Final SECAP report 12/13/06
Section 1.
Practice Site Characteristics
This section addresses practice site characteristics. In this survey, the term “practice site” is
used to refer to the specific site identified in the cover letter. In a hospital setting, practice site
refers to a specific department, division, clinic or endoscopy suite. In a non-hospital setting,
practice site refers to a physician practice or ambulatory center. Responses should reflect only
the procedures performed at the practice site, as identified in the cover letter.
If you are unable to respond to a specific question, please feel free to consult with others in your
practice who may be more familiar with certain types of information.
1.
Which of the following categories best describes the practice site identified in the cover
letter? (Circle one response)
Private practice............................................1
Ambulatory endoscopy/surgery center .......2
Hospital .......................................................3
If you answered ‘private practice’ or ‘ambulatory
endoscopy/surgery center’ to Question 1, please skip to
Question 5.
If you answered ‘hospital’ to Question 1, please continue
with Question 2.
2.
Please indicate whether or not flexible sigmoidoscopy and/or colonoscopy are performed at
any of the following sites in this hospital? (Circle 1 for yes or 2 for no)
a.
b.
c.
d.
e.
f.
g.
h.
YES
NO
↓
↓
Gastroenterology department .....................................................................1
General surgery department .......................................................................1
Colorectal surgery department ...................................................................1
Family practice department ........................................................................1
General internal medicine department .......................................................1
Operating room ..........................................................................................1
Satellite clinic .............................................................................................1
Other (specify______________________________________) ................1
2
2
2
2
2
2
2
2
B-6
Colorado Final SECAP report 12/13/06
3.
How many patient beds does your hospital contain?
Number of beds
4.
Which of the following describes this location? (Circle one response)
Gastroenterology department .....................................................................1
General surgery department .......................................................................2
Colorectal surgery department ...................................................................3
Family practice department ........................................................................4
General internal medicine department .......................................................5
Operating room ..........................................................................................6
Satellite clinic .............................................................................................7
Other (specify)___________________ .....................................................8
5.
How many physicians (e.g., surgeons, medical doctors, and doctors of osteopathy) are in
this practice site?
Number of physicians
6.
What is the medical specialty of the physicians in this practice site? (Please provide the
total NUMBER for each medical specialty. Include doctors who have privileges as
well as doctors employed by the practice site)
a. Family Practice
b. General Practice
c. Internal Medicine
d. Gastroenterology
e. General Surgery
f. Colorectal Surgery
g. Other Physicians
B-7
Colorado Final SECAP report 12/13/06
7.
How many of the following physicians in this practice site perform flexible sigmoidoscopy
and/or colonoscopy? (Please provide a NUMBER, not a percentage)
a. Family Practice
b. General Practice
c. Internal Medicine
d. Gastroenterology
e. General Surgery
f. Colorectal Surgery
g. Other Physicians
8.
Do interns, residents or fellows receive sigmoidoscopy or colonoscopy training in this
practice site?
yes ...............1
no ...............2
9.
How many of the following types of flexible sigmoidoscopes and colonoscopes does this
practice site own?
a. Colonoscopes, fiberoptic
b. Colonoscopes, with video
c. Flexible sigmoidoscopes, 70 cm, fiberoptic
d. Flexible sigmoidoscopes, 70 cm, with video
e. Flexible sigmoidoscopes, 60 cm, fiberoptic
f. Flexible sigmoidoscopes, 60 cm, with video
g. Flexible sigmoidoscopes, 30 cm, fiberoptic
h. Flexible sigmoidoscopes, 30 cm, with video
i. Other lower endoscopes (specify type_____)
B-8
Colorado Final SECAP report 12/13/06
10.
During a typical week, approximately how many patients are seen at this practice site for
any reason, including for procedures? (Circle one response)
75 or fewer ..............1
76-150 .....................2
151-300 ...................3
301-500 ...................4
501 or more .............5
Section 2.
Flexible Sigmoidoscopy
In this section we ask about flexible sigmoidoscopies performed at this practice site for
colorectal cancer screening or follow-up. We use the term screening to refer to the routine,
periodic use of a testing procedure intended to detect cancer or pre-cancerous lesions at an
earlier stage than is possible through clinical detection or incidental discovery. Colorectal
cancer screening is used in individuals who have no signs or symptoms of possible cancer (i.e.,
abdominal pain or tenderness, change in bowel habits, bleeding, anemia, an abdominal or rectal
mass, evidence of bowel obstruction, or weight loss) and have not had a neoplastic lesion
previously diagnosed.
If you are unable to provide exact responses, please provide your best estimate. If you are
unable to answer certain questions (e.g., questions regarding appointment availability or
reimbursement rate), please feel free to consult with others in your practice who may be more
familiar with this type of information.
11.
Are any flexible sigmoidoscopies performed at this site?
yes ...............1
no.................2
12.
SKIP TO QUESTION 24
During a typical week, how many flexible sigmoidoscopies are performed at this practice
site? (Please provide your best estimate, including both screening and diagnostic
examinations)
Total number of sigmoidoscopies
per week
13.
Approximately what percentage of all flexible sigmoidoscopies are performed for
colorectal cancer screening? (Please provide your best estimate)
Percent performed for colorectal cancer screening
B-9
%
Colorado Final SECAP report 12/13/06
14.
15.
Of the total number of flexible sigmoidoscopies performed during a typical week in this
practice, what percentage is performed by the following types of practitioners? (Please
provide your best estimate)
a. General practitioner
%
b. Internist
%
c. Family practitioner
%
d. Gastroenterologist
%
e. General surgeon
%
f. Colorectal surgeon
%
g. Resident with supervising
physician in attendance
%
h. Fellow with supervising
physician in attendance
%
i. Non-physician endoscopist
%
j. Other (Specify): ________
%
How much room-time is scheduled for a flexible sigmoidoscopy?
(Circle one response)
15-30 minutes..................................1
30 minutes-45 minutes....................2
More than 45 minutes .....................3
16.
In this practice site, approximately what percentage of flexible sigmoidoscopies performed
in a week are incomplete?
%
B-10
Colorado Final SECAP report 12/13/06
17.
What is the most common reason for an incomplete flexible sigmoidoscopy? (Circle one
response)
Poor bowel preparation .........................1
Patient discomfort or pain.....................2
Patient anatomy.....................................3
Other (Specify_________________)....4
18.
If a flexible sigmoidoscopy is incomplete because of poor bowel preparation, patient
discomfort or pain, or patient anatomy, what would be your next step?
(Circle one number for each column)
a. Poor bowel
preparation
b. Patient
discomfort or
pain
c. Patient
anatomy
Reason for Incomplete
Procedure
Repeat the flexible sigmoidoscopy at a later date......................
1
1
1
Refer the patient to another practice for sigmoidoscopy ...........
2
2
2
Perform a colonoscopy ..............................................................
3
3
3
Refer the patient to another practice for colonoscopy ...............
Order a double contrast barium enema ......................................
4
4
4
5
5
5
Other (Specify____________________________________)
6
6
6
19.
Does this practice site routinely perform biopsies during a screening flexible
sigmoidoscopy?
yes ...............1
no.................2
SKIP TO QUESTION 21
B-11
Colorado Final SECAP report 12/13/06
20.
What action do you typically take if a lesion of the characteristics described below is
identified during a screening flexible sigmoidoscopy in a healthy, average-risk patient?
(Circle one number for each column)
a. Polyp <5mm
b. Polyp 0.51cm
c. Polyp >1cm
d. Multiple
polyps
Lesion
Perform the biopsy during the sigmoidoscopy ..........................
1
1
1
1
Conclude the sigmoidoscopy and schedule a
colonoscopy with biopsy............................................................
2
2
2
2
Conclude the sigmoidoscopy with no further follow-up and
resume a routine colorectal cancer screening schedule .............
3
3
3
3
Other (Specify____________________________________)
4
4
4
4
21.
If the demand for colorectal cancer screening were to increase substantially, what is the
maximum number of flexible sigmoidoscopies that could be provided at this practice site
per week with no other investment of resources? (Please provide your best estimate)
Maximum number per
week
22.
If the demand for screening flexible sigmoidoscopy were to exceed your current capacity to
perform screening flexible sigmoidoscopy, what steps would your practice take to meet the
increased demand? (Circle 1 for yes or 2 for no for a-h)
a.
b.
c.
d.
e.
f.
g.
YES
NO
↓
↓
Increase proportion of the work day allocated to procedures .....................1
Increase physician staff...............................................................................1
Increase nursing staff to assist with procedures..........................................1
Increase/hire non-physician endoscopists to perform procedures ..............1
Establish a larger screening unit/more procedure rooms ............................1
Purchase more equipment ...........................................................................1
Refer patients to other practices..................................................................1
2
2
2
2
2
2
2
B-12
Colorado Final SECAP report 12/13/06
h. Other (Specify______________________________________)................1
23.
2
What is the typical waiting time for an appointment for a screening flexible sigmoidoscopy
in your practice? (Circle one response)
Within one month ........................1
1-3 months ...................................2
4-6 months ...................................3
More than six months...................4
Section 3.
Colonoscopy
In this section we ask about colonoscopies performed at this practice site. We are inquiring
about colonoscopies pertaining to colorectal cancer screening, including those performed for
primary screening, those performed for the diagnosis of an abnormality identified through
another screening procedure, and those performed for surveillance in a patient with a previously
identified colorectal polyp or cancer.
If you are unable to provide exact responses, please provide your best estimate. If you are
unable to answer certain questions (e.g., questions regarding appointment availability or
reimbursement rate), please feel free to consult with others in your practice who may be more
familiar with this type of information.
24.
Are any colonoscopies performed at this site?
yes ...............1
no.................2
25.
SKIP TO QUESTION 36
During a typical week, how many colonoscopies are performed at this practice site?
(Please provide your best estimate, including both screening and diagnostic
examinations)
Total number of
colonoscopies
per
week
26.
Approximately what percentage of all colonoscopies are performed for colorectal cancer
screening? (Please provide your best estimate)
Percent performed for colorectal cancer screening
B-13
%
Colorado Final SECAP report 12/13/06
27.
28.
Of the total number of colonoscopies performed during a typical week, what percentage is
performed by the following types of practitioners? (Please provide your best estimate)
a. General practitioner
%
b. Internist
%
c. Family practitioner
%
d. Gastroenterologist
%
e. General surgeon
%
f. Colorectal surgeon
%
g. Resident with supervising
physician in attendance
%
h. Fellow with supervising
physician in attendance
%
i. Non-physician endoscopist
%
j. Other (Specify): ________
%
How much room-time is scheduled for a colonoscopy? (Circle one response)
Less than 30 minutes.......................1
30 minutes-45 minutes....................2
More than 45 minutes .....................3
29.
In this practice site, approximately what percentage of colonoscopies performed in a week
are incomplete?
%
B-14
Colorado Final SECAP report 12/13/06
30.
What is the most common reason for an incomplete colonoscopy? (Circle one response)
Poor bowel preparation .........................1
Patient discomfort or pain.....................2
Patient anatomy.....................................3
Other (Specify_________________)....4
31.
If a colonoscopy is incomplete because of poor bowel preparation, patient discomfort or
pain, or patient anatomy, what would be your next step?
(Circle one number for each column)
a. Poor bowel
preparation
b. Patient
discomfort or
pain
c. Patient
anatomy
Reason for Incomplete
Procedure
Repeat the colonoscopy at a later date.......................................
1
1
1
Refer the patient to another practice for colonoscopy ...............
Order a double contrast barium enema ......................................
2
2
2
3
3
3
Other (Specify____________________________________)
4
4
4
32.
If the demand for colorectal cancer screening and follow-up were to increase substantially,
what is the maximum number of colonoscopies that could be provided at this practice site
per week with no other investment of resources? (Please provide your best estimate)
Maximum number per
week
B-15
Colorado Final SECAP report 12/13/06
33.
If the demand for colonoscopies were to exceed your current capacity to perform
colonoscopies, what steps would your practice take to meet that increased demand?
(Circle 1 for yes or 2 for no for a-h)
a.
b.
c.
d.
e.
f.
g.
h.
34.
YES
NO
↓
↓
Increase proportion of the work day allocated to procedures .....................1
Increase physician staff...............................................................................1
Increase nursing staff to assist with procedures..........................................1
Increase/hire non-physician endoscopists to perform procedures ..............1
Establish a larger screening unit/more procedure rooms ............................1
Purchase more equipment ...........................................................................1
Refer patients to other practices..................................................................1
Other (Specify______________________________________)................1
2
2
2
2
2
2
2
2
What is the typical waiting time for an appointment for a screening colonoscopy at your
practice site? (Circle one response)
Within one month ........................1
1-3 months ...................................2
4-6 months ...................................3
More than six months...................4
35.
What is the typical waiting time to have a colonoscopy performed at your practice site to
follow-up on a problem identified in a screening procedure? (Circle one response)
Within one month ........................1
1-3 months ...................................2
4-6 months ...................................3
More than six months...................4
36.
What is the typical waiting time for a referral to another clinic for a colonoscopy to followup on a problem identified in a screening procedure? (Circle one response)
Within one month ........................1
1-3 months ...................................2
4-6 months ...................................3
More than six months...................4
Do not refer to another facility.....5
B-16
Colorado Final SECAP report 12/13/06
Section 4.
Non-physician Endoscopists
This section focuses on the use of non-physician endoscopists to perform sigmoidoscopy or
colonoscopy in this practice site. Non-physician endoscopists include nurse practitioners,
physician assistants, registered nurses, and licensed practical nurses.
37.
Does this practice site employ non-physician endoscopists (e.g., nurse practitioners,
physician assistants, registered nurses, and licensed practical nurses) to perform
sigmoidoscopy or colonoscopy?
yes ...............1
no.................2
38.
SKIP TO QUESTION 42
How many of the following non-physician endoscopists perform sigmoidoscopy or
colonoscopy in this practice site?
a. Licensed Practical Nurse
b. Registered Nurse
c. Nurse Practitioner
d. Physician Assistant
39.
When a non-physician endoscopist performs a flexible sigmoidoscopy, what level of
supervision is provided? (Circle one response)
A physician is present in the procedure room for the entire exam ...................... 1
A physician is present in the procedure room when the flexible
sigmoidoscope is withdrawn only...................................................................2
The non-physician endoscopist is authorized to perform the exam in entirety,
unsupervised by a physician, but . . .
A physician is “immediately available” in clinic.........................................3
A physician is “immediately available” in hospital.....................................4
A physician is “immediately available” by beeper/phone ...........................5
The non-physician endoscopist is authorized to perform the exam in entirety,
unsupervised by a physician ...........................................................................6
Non-physician endoscopists do not perform flexible sigmoidoscopy ..................7
Other (Specify): ________________ ..................................................................8
B-17
Colorado Final SECAP report 12/13/06
40.
When a non-physician endoscopist performs a colonoscopy, what level of supervision is
provided? (Circle one response)
A physician is present in the procedure room for the entire exam .......................1
A physician is present in the procedure room when the colonoscope is
withdrawn only ...............................................................................................2
The non-physician endoscopist is authorized to perform the exam in entirety,
unsupervised by a physician, but . . .
A physician is “immediately available” in clinic.........................................3
A physician is “immediately available” in hospital.....................................4
A physician is “immediately available” by beeper/phone ...........................5
The non-physician endoscopist is authorized to perform the exam in entirety,
unsupervised by a physician ...........................................................................6
Non-physician endoscopists do not perform colonoscopy ...................................7
Other (Specify): ________________ ..................................................................8
41.
When a non-physician endoscopist performs a flexible sigmoidoscopy or colonoscopy, to
whom is the reimbursement assigned? (Circle one response)
The non-physician endoscopist .................................1
The practice................................................................2
A staff physician ........................................................3
The hospital................................................................4
The practice does not receive reimbursement............5
Other (Specify_________________________).........6
Section 5.
42.
Patient, Practice and Respondent Characteristics
Approximately what percentage of patients seen at this practice site are female?
(Circle one response)
Less than 25% .....................1
25-49%................................2
50-74%................................3
75-100%..............................4
43.
Approximately what percentage of patients seen at this practice site are 50 years of age or
older? (Circle one response)
Less than 25% .....................1
25-49%................................2
50-74%................................3
75-100%..............................4
B-18
Colorado Final SECAP report 12/13/06
44.
Approximately what percentage of the patients seen at this practice site are:
(Circle one response for each row)
a.
b.
c.
d.
e.
f.
45.
46.
American Indian or Alaska Native ..............
Asian ............................................................
Black or African-American..........................
Native Hawaiian or other Pacific Islander ...
Hispanic or Latino........................................
White ............................................................
<25%
25-49%
50-74%
75-100%
0
0
0
0
0
0
1
1
1
1
1
1
2
2
2
2
2
2
3
3
3
3
3
3
4
4
4
4
4
4
Approximately what percentage of your patients are covered by:
a. Medicare?
%
b. Medicaid?
%
c. Private fee-for-service?
%
d. Managed Care (including
HMO, PPO, IPA and POS ) Plans?
%
e. Medicare/ Medicaid/ Managed Care?
%
f. No insurance coverage?
%
Please indicate whether or not your facility is one of the following types of medical
facilities. (Circle 1 for yes or 2 for no for a-d)
a.
b.
c.
d.
47.
None
YES
NO
↓
↓
Staff model health maintenance organization.............................................1
Group model health maintenance organization ..........................................1
Military hospital..........................................................................................1
Veterans Administration Medical Center ...................................................1
2
2
2
2
What percentage of your patients travel from more than 50 miles away to have a
sigmoidoscopy or colonoscopy at your facility?
%
Percentage of patients
B-19
Colorado Final SECAP report 12/13/06
48.
What is your professional training? (Circle one response)
MD ..........................................................................1
DO ...........................................................................2
Nurse endoscopist ..................................................3
Nurse .......................................................................4
Other (Specify): ___________________ ...............5
49.
SKIP TO QUESTION 51
SKIP TO QUESTION 51
SKIP TO QUESTION 51
What is your medical specialty? (Circle all that apply)
Family Practice .......................................................1
General Practice ......................................................2
Internal Medicine ....................................................3
Gastroenterology.....................................................4
General Surgery ......................................................5
Colorectal Surgery ..................................................6
Other (Specify): ___________________ ...............7
50.
In which specialty/sub-specialty have you completed residency or fellowship training?
(Circle all that apply)
Family Practice .......................................................1
Internal Medicine ....................................................2
Gastroenterology.....................................................3
General Surgery ......................................................4
Colon Rectal Surgery..............................................5
Other(Specify): ___________________ ................6
51.
Approximately what percentage of the physicians in this practice site are:
(Circle one response for each row)
a.
b.
c.
d.
e.
f.
American Indian or Alaska Native ..............
Asian ............................................................
Black or African-American..........................
Native Hawaiian or other Pacific Islander ...
Hispanic or Latino........................................
White............................................................
B-20
None
<25%
25-49%
50-74%
75-100%
0
0
0
0
0
0
1
1
1
1
1
1
2
2
2
2
2
2
3
3
3
3
3
3
4
4
4
4
4
4
Colorado Final SECAP report 12/13/06
APPENDIX C
COUNTIES BY COLORADO REGIONS
1=Denver Metro
Adams
Arapahoe
Boulder
Denver
Douglas
Jefferson
2=Southwest
Alamosa
Archuleta
Conejos
Costilla
Delta
Dolores
Gunnison
Hinsdale
La Plata
Mineral
Montezuma
Montrose
Ouray
Rio Grande
Saguache
San Juan
San Miguel
3=Eastern Plains
Baca
Bent
Cheyenne
Crowley
Elbert
Kiowa
Kit Carson
Lincoln
Logan
Morgan
Otero
Phillips
Prowers
Sedgwick
Washington
Yuma
4=South Central Mountain
Chaffee
Clear Creek
Custer
Fremont
Gilpin
Huerfano
Lake
Las Animas
Park
Teller
C-1
5=Northwest
Eagle
Garfield
Grand
Jackson
Mesa
Moffat
Pitkin
Rio Blanco
Routt
Summit
6=El Paso/Pueblo
El Paso
Pueblo
7=Larimer/Weld
Larimer
Weld
Colorado Final SECAP report 12/13/06
APPENDIX D
Multinomial Logistic Regression Results for Colorado
FOBT
Coefficient
Male
Hispanic
Other Non-Hispanic
Ages 50 to 59
Age 65 and older
<250% of Poverty Level
Health Insurance
Region 2
Region 3
Region 4
Region 5
Region 6
Region 7
2002 BRFSS
Income Missing
Intercept
-0.318
-0.491
0.196
-0.427
0.107
-0.438
0.250
-0.320
-0.047
0.245
-0.332
-0.361
-0.254
0.194
-0.251
-1.193
Endoscopy
Standard
Error
Coefficient
0.137
0.254
0.277
0.196
0.201
0.192
0.283
0.264
0.292
0.268
0.230
0.209
0.250
0.132
0.200
0.326
-0.030
-0.449
-0.048
-0.619
0.124
-0.216
1.186
-0.191
-0.462
-0.109
0.069
0.150
0.199
-0.039
-0.044
-1.071
D-1
Standard
Error
0.097
0.177
0.186
0.142
0.139
0.162
0.230
0.170
0.238
0.197
0.158
0.146
0.159
0.099
0.142
0.275
FOBT and Endoscopy
Coefficient
-0.022
-0.942
-0.315
-0.884
0.356
-0.225
1.692
-1.167
-0.877
-1.614
-0.614
-0.359
-0.334
0.091
-0.480
-2.034
Standard Error
0.120
0.265
0.270
0.183
0.180
0.161
0.438
0.258
0.358
0.377
0.225
0.173
0.213
0.119
0.194
0.443
| File Type | application/pdf |
| File Title | Microsoft Word - Final SECAP CO report.doc |
| Author | BLESSINGK |
| File Modified | 2006-12-13 |
| File Created | 2006-12-13 |