Table 1 Historical barriers to CRC screening (n = 55)

Too many options in the system for screening and no clear guidelines for providers or patients

“It’s amazing the paucity of evidence around what’s really the best test. The stool cards have been tested more rigorously than other interventions, so we know more about that. But that doesn’t necessarily mean we know that colonoscopy is not as good.” —HP leader

Mixed-message received from health plan because of allowing referral for screening colonoscopies, but not having full support to get the colonoscopies done

“Initially, there was tremendous resistance to doing colonoscopies on people that didn’t have a first degree relative with a history of colon cancer. And, we were under-utilizing the hemoccults. But we would get into a twenty minute debate with a patient who wanted a colonoscopy… So, I never know what’s right or whether our system just had it’s resources in the wrong place. First they tell you to do one thing in the system, then it changes… it makes you dizzy.” —PCP

Prior organizational focus on fecal tests and flexible sigmoidoscopy not matching community standard or national recommendations

“The community standard for screening is colonoscopy as recommended by the American Society of Gastroenterologists… Then [patients] say, ‘Well, the Internet’s kind of said that that’s really the best thing to do.’ And then we have to say, ‘Well, we’re not offering that to you.’ And that can be quite contradictory. And having that conversation can be quite challenging.” —General surgeon

PCPs and specialists influenced by training or culture promote only screening colonoscopy and not other options (e.g., fecal test) for low-risk patients

“A lot of the younger primary care docs… were influenced by… one of the leaders in the field… [The] one lecture a year he gave to the house staff was that colonoscopy is the way to go.” —GI specialist

Restricted access to screening colonoscopy within the organization

“How tight the access issue is, is an ongoing sort of challenge and frustration for the GI department.” —GI specialist

PCPs ordering screening colonoscopies when the patient is symptomatic, rather than as a diagnostic test, complicates triaging a limited resource

“I think our system would benefit if we actually went back to basics… It seems like we get a lot of referrals for screening when the patient has abdominal bloating or they have diarrhea. It’s not clear if the other person on the other end understands what the term screening really means… That really blurs the triaging to try to figure out which patients to see first and get things done effectively.” —GI specialist

Over-screening the already screened or offering screening to those who may not need it (e.g., patient on hospice care) complicates triaging a limited resource

“People with a life expectancy of less than five years, it makes absolutely no sense to offer them colon cancer screening, but we see this all the time. Or if they have Class 4 heart failure, or if they have some other cancer that has failed chemotherapy and they’re on hospice.” —GI specialist

Lack of time during office visit and addressing patients’ competing demands makes thoroughly discussing CRC screening and options difficult

“I find it hard when someone is in for something else and these [CRC screening] orders get pended, that I don’t feel like talking about in that visit because they’ve just been diagnosed with diabetes or there’s something really pressing going on that I need to talk about with the patient… it’s not the time to talk about colon cancer screening.” —PCP

Hard to negotiate both patient demand and offer “choice” of test while also honoring organizational emphasis on fecal testing

“As a clinician here, since we aren’t pushing or embracing the idea of colonoscopy as primary screening, the conversations I end up having to have with patients who want colonoscopy [involve] talking about a long wait time in getting them a colonoscopy if they want it, even though it’s not our first recommendation.” —PCP

Referral process for a screening colonoscopy involves multiple steps and departments, which sometimes creates miscommunication and lack of follow-up

“The referral is more challenging than for something like a Pap, which I can do it when they come in. I have more control over that. As opposed to CRC screening [colonoscopy] and having to send in a referral, having the patient be called back or a letter sent. It’s just more steps to get in.” —PCP

Specialists tend to have a limited historical role in helping to shape organization’s CRC screening approach

“The (surgery) department hasn’t really provided any leadership around influencing colon cancer screening. They’ve played a passive role, for the most part, in supporting what was the flex sig [sic] program as an orphan department. I don’t recollect surgeons being on the colon cancer screening meetings for the last number of years.” —General surgeon