[INSERT HERE: HEALTH SYSTEM LOGO]
Health Care Systems for Increasing and Tracking
Colorectal Cancer Screening Tests
Physicians and Other Clinicians—Complete Sections A To D.
All Other Staff—Complete Section C Only.
Anonymous ID: ______________________
Role in the Practice:
___ Physician
___ Other clinician (CRNP, PA)
___ Other clinical staff (specify) ______________________
___ Other office staff (specify) ______________________
Practice ID ______________________
Date ___ / ___ / ___ (MM/DD/YYYY)
CONFIDENTIALITY: [INSERT HERE: CONFIDENTIALITY STATEMENT]
A. Colorectal Cancer Screening Practices (Physicians and Other Clinicians)
This section asks about different approaches to colorectal cancer screening. Please respond based on how you actually practice, even if this differs from how you would prefer to practice.
A-1. How frequently do you recommend the following tests for colorectal cancer screening to your asymptomatic, average-risk patients age 50 and older?
Check one box on each line.
| Tests | Very frequently |
Somewhat frequently |
Not frequently |
Never |
|---|---|---|---|---|
| A. Colonoscopy | 1 ___ | 2 ___ | 3 ___ | 4 ___ |
| B. Stool test alone | ||||
| Fecal occult blood test (FOBT) | 1 ___ | 2 ___ | 3 ___ | 4 ___ |
| Fecal immunochemical test (FIT) | 1 ___ | 2 ___ | 3 ___ | 4 ___ |
| Stool DNA test | 1 ___ | 2 ___ | 3 ___ | 4 ___ |
| C. Other | ||||
| Flexible sigmoidoscopy | 1 ___ | 2 ___ | 3 ___ | 4 ___ |
| Virtual colonoscopy (CT colonography) | 1 ___ | 2 ___ | 3 ___ | 4 ___ |
| Double contrast barium | 1 ___ | 2 ___ | 3 ___ | 4 ___ |
| Digital rectal exam | 1 ___ | 2 ___ | 3 ___ | 4 ___ |
A-2 How effective do you believe the following tests are in reducing colorectal cancer mortality in asymptomatic, average-risk patients age 50 and older?
Check one box on each line.
| Tests | Very effective |
Somewhat effective |
Not effective |
Don't know |
|---|---|---|---|---|
| A. Colonoscopy | 1 ___ | 2 ___ | 3 ___ | 4 ___ |
| B. Stool test alone | ||||
| Fecal occult blood test (FOBT) | 1 ___ | 2 ___ | 3 ___ | 4 ___ |
| Fecal immunochemical test (FIT) | 1 ___ | 2 ___ | 3 ___ | 4 ___ |
| Stool DNA test | 1 ___ | 2 ___ | 3 ___ | 4 ___ |
| C. Other | ||||
| Flexible sigmoidoscopy | 1 ___ | 2 ___ | 3 ___ | 4 ___ |
| Virtual colonoscopy (CT colonography) | 1 ___ | 2 ___ | 3 ___ | 4 ___ |
| Double contrast barium | 1 ___ | 2 ___ | 3 ___ | 4 ___ |
| Digital rectal exam | 1 ___ | 2 ___ | 3 ___ | 4 ___ |
B. Case Scenarios (Physicians and Other Clinicians)
We would like your thoughts about the followup of these two hypothetical patients.
B-1.Your office is involved in a colorectal cancer screening program that involves sending stool tests to patients age 50 and older. Patients may complete and return stool test cards to a central lab for processing. Your office is informed of an abnormal screening test result for one of your patients.
What would you routinely do when you are informed that a patient has a positive stool test result?
Would you recommend . . .
Check all that apply:
- ___ Repeat stool test?
- ___ Flexible sigmoidoscopy?
- ___ Colonoscopy?
- ___ Double contrast enema?
- ___ Other? (Specify) ______________________
B-2. Your office is involved in a colorectal cancer screening program that offers flexible sigmoidoscopy to patients age 50 and older. Patients may undergo a screening flexible sigmoidoscopy examination. Your office is informed of an abnormal test result for one of your patients.
What would you routinely do when you are informed that a patient has an abnormal flexible sigmoidoscopy result?
Would you recommend . . .
Check all that apply:
- ___ Stool test?
- ___ Repeat flexible sigmoidoscopy?
- ___ Colonoscopy?
- ___ Double contrast enema?
- ___ Other? (Specify) ______________________
C. Colorectal Cancer Screening Process in Your Office (Physicians, Other Clinicians, and ALL Other Staff)
This section asks about how the colorectal cancer screening process occurs in your office. Please respond based on how this process actually works in your practice, even if this differs from how you would prefer things to work.
C-1. For screening stool tests, who in your practice actually performs the activity involved in each step below?
Check all that apply.
| Activity | I do it | Another person does it (specify job title) |
No one does it | Don't know |
|---|---|---|---|---|
| A. Gives stool test cards to the patient | 1 ___ | 2 ___
______________________ |
3 ___ | 4 ___ |
| B. Contacts nonresponders to stool test | 1 ___ | 2 ___
______________________ |
3 ___ | 4 ___ |
| C. Gives stool test results to patient | 1 ___ | 2 ___
______________________ |
3 ___ | 4 ___ |
| D. Refers patients with positive stool test for followup | 1 ___ | 2 ___
______________________ |
3 ___ | 4 ___ |
| E. Schedules followup for positive stool test patients | 1 ___ | 2 ___
______________________ |
3 ___ | 4 ___ |
| F. Contacts followup no-shows | 1 ___ | 2 ___
______________________ |
3 ___ | 4 ___ |
| G. Reschedules no-shows for followup | 1 ___ | 2 ___
______________________ |
3 ___ | 4 ___ |
C-2. For screening flexible sigmoidoscopy, who in your practice actually performs the activity involved in each step below?
Check all that apply.
| Activity | I do it | Another person does it (specify job title) |
No one does it | Don't know |
|---|---|---|---|---|
| A. Orders screening flexible sigmoidoscopy | 1 ___ | 2 ___
______________________ |
3 ___ | 4 ___ |
| B. Schedules flexible sigmoidoscopy | 1 ___ | 2 ___
______________________ |
3 ___ | 4 ___ |
| C. Contacts flexible sigmoidoscopy no-shows | 1 ___ | 2 ___
______________________ |
3 ___ | 4 ___ |
| D. Reschedules no-shows for flexible sigmoidoscopy | 1 ___ | 2 ___
______________________ |
3 ___ | 4 ___ |
C-3. For screening colonoscopy, who in your practice actually performs the activity involved in each step below?
Check all that apply.
| Activity | I do it | Another person does it (specify job title) |
No one does it | Don't know |
|---|---|---|---|---|
| A. Orders screening colonoscopy | 1 ___ | 2 ___
______________________ |
3 ___ | 4 ___ |
| B. Schedules colonoscopy | 1 ___ | 2 ___
______________________ |
3 ___ | 4 ___ |
| C. Contacts colonoscopy no-shows | 1 ___ | 2 ___
______________________ |
3 ___ | 4 ___ |
| D. Reschedules no-shows for colonoscopy | 1 ___ | 2 ___
______________________ |
3 ___ | 4 ___ |
D. Background of Your Patients and Yourself (Physicians and Other Clinicians Only)
D-1a During the past 12 months, how many (number) newly diagnosed colorectal cancer patients have you personally seen in your practice? An estimate is fine.
|______________________| newly diagnosed colorectal cancer patients
D-1b During the past 12 months, how many (number) newly diagnosed colorectal adenomatous polyp patients have you personally seen in your practice? An estimate is fine.
|______________________| newly diagnosed colorectal adenomatous polyp patients
D-2a During the past 12 months, approximately what percentage (%) of your newly diagnosed colorectal cancer patients was diagnosed because they had a symptom (e.g., hematochezia, weight loss, abdominal pain, or bloating)? An estimate is fine.
|______________________|% of newly diagnosed colorectal cancer patients
D-2b During the past 12 months, approximately what percentage (%) of your newly diagnosed colorectal adenomatous polyp patients was diagnosed because they had a symptom? An estimate is fine.
|______________________|% of newly diagnosed colorectal adenomatous polyp patients
D-3a During the past 12 months, approximately what percentage (%) of your newly diagnosed colorectal cancer patients was diagnosed because they had a positive FOBT result? An estimate is fine.
|______________________|% of newly diagnosed colorectal cancer patients
D-3b During the past 12 months, approximately what percentage (%) of your newly diagnosed adenomatous polyp patients was diagnosed because they had a positive FOBT result? An estimate is fine.
|______________________|% of newly diagnosed colorectal adenomatous polyp patients
D-4. On average, how many patients do you see each week?
- ___ Fewer than 100
- ___ 100-124
- ___ 125-149
- ___ 150 or more
D-5. What is your date of birth? ___ / ___ / ___
D-6. What is your gender? 1 ___ Male 2 ___ Female
D-7. Do you consider yourself to be Hispanic or Latino? 1 ___ Yes 2 ___ No
D-8. Do you consider yourself to be . . .
Check all that apply:
- ___ American Indian or Alaska Native
- ___ Asian
- ___ Black or African American
- ___ Native Hawaiian or Other Pacific Islander
- ___ White
D-9. Do you as an individual have an affiliation with a medical school or nursing school, such as adjunct, clinical, or other faculty appointment?
- ___ Yes (Specify the medical or nursing school) ______________________
- ___ No
D-10. Physicians only—What is your primary medical specialty?
Check one box:
- ___ Family medicine
- ___ General practice
- ___ General internal medicine
- ___ Obstetrics/gynecology
- ___ Other (specify)______________________
D-11. Physicians only: Are you board certified in that specialty? 1 ___ Yes 2 ___ No
D-12a. Physicians only: In what year did you graduate from medical school?
________ (4-Digit Year)
D-12b. Other clinicians only: In what year did you receive your highest clinical degree?
________ (4-Digit Year)
