摘要：Objectives. We aimed to highlight sociodemographic differences in how patients access colonoscopy. Methods. We invited all eligible patients (n = 2500) from 2 academy-affiliated colonoscopy centers in Alachua County, Florida (1 free standing, 1 hospital based), to participate in a precolonoscopy survey (September 2011–October 2013); patients agreeing to participate (n = 1841, response rate = 73.6%) received a $5.00 gift card. Results. We found sociodemographic differences in referral pathway, costs, and reasons associated with obtaining the procedure. Patients with the ideal pathway (referred by their regular doctor for age-appropriate screening) were more likely to be Black (compared with other minorities), male, high income, employed, and older. Having the colonoscopy because of symptoms was associated with being female, younger, and having lower income. We found significant differences for 1 previously underestimated barrier, having a spouse to accompany the patient to the procedure. Conclusions. Patients’ facilitators and barriers to colonoscopy differed by sociodemographics in our study, which implies that interventions based on a single facilitator will not be effective for all subgroups of a population. Colorectal cancer (CRC), the second leading cause of US cancer deaths in 2013 (50 830), 1 is not distributed equally. Nationally, it is estimated that incidence is 25% higher, and mortality from CRC 50% higher, in Black Americans than in Whites. 2,3 Most CRC diagnoses follow evaluation by colonoscopy. Although consumers have a range of CRC screening tests, from least invasive (fecal occult blood test, fecal immunochemical test) to most invasive (sigmoidoscopy, colonoscopy), 4 if polyps are indicated, a colonoscopy is required as follow-up. Thus, colonoscopy is both an entry point and a pivotal event in the process of preventing, detecting, and treating CRC. CRC can be prevented through the removal of precancerous polyps or detected at an early, easily treatable stage 5 ; findings indicate 6 that colonoscopy with polypectomy reduces mortality from CRC by 53%. Although rates of CRC screening have increased, 3 there is need for improvement. More than one third of Americans are not in compliance with screening guidelines, 7 with rates being lower in the southern United States. 8 In 2008, Etzioni et al. 9 presented a model of patient and provider-level factors that influence decision-making in colon cancer and that can lead to health disparities in disease recurrence and survival. The Etzioni model identifies key points of vulnerability in the treatment process where the potential to achieve high-quality, guideline-recommended care can be lost. The model captures patients after surgery, beginning with the decision to refer patients to a medical oncologist for adjuvant treatment; it is relevant because there is considerable evidence of inequities in who receives adjuvant treatment based on older age, 10,11 comorbidities, 12,13 low income, 7 coverage with Medicaid rather than Medicare, 13 Black race, 14 female gender, 15,16 and being unmarried. 9 We propose that this model starts too late in the process; health disparities originate prior to colonoscopy and can increase at each decision point along a continuum. In an elaborated model ( Figure 1 ), we suggest that CRC health disparities research should begin with an investigation of entry into the health care system and the subsequent pathways to colonoscopy. Referral patterns, costs, and patient demographics influence patient access to care, colonoscopy compliance, and postcolonoscopy decision-making. Open in a separate window FIGURE 1— Pathways to colonoscopy, treatment, and outcomes.
