Multi-level Factors Influencing Decisions About Stopping Surveillance Colonoscopy in Older Adults: a Qualitative Study

We interviewed 13 GIs, 12 PCPs, and 15 patients. Table 2 describes the characteristics of our sample. Among the GIs, four (31%) were female and their mean number of years in practice was 17. Among the PCPs, eight (66%) were female and their mean number of years in practice was 19. Among the patients, eight (53%) were female, and 5 (33%) were  ≥ 75. Most (73%) had attended college.

Table 2 Characteristics of the Gastroenterologist, Primary Care Provider, and Patient Participants

We achieved saturation by interview 11 with patients, 10 with PCPs and 9 with GIs. While we could have ceased interviewing additional participants after this point, ongoing scheduling in conjunction with coding resulted in the additional interviews. Through cross-comparisons during analysis, we identified 24 themes that promoted stopping or continuing surveillance which clustered into three main categories (see Fig. 1): (1) health and clinical considerations; (2) communication and roles; and (3) system-level processes or structures. As indicated, some themes were specific to one group (e.g., patients) and others were related to two or all three participant groups. Below we provide an overall summary of themes in each category and example quotes.

Figure 1figure 1

Themes that promoted stopping or continuing surveillance.

Themes in Health and Clinical Considerations

Nine themes emerged in health and clinical considerations. Three of the five themes that promoted stopping surveillance colonoscopies centered on poor health or life expectancy. PCPs and GIs then often tied these to the related themes of increased colonoscopy risks particularly for patients with comorbidities. On the flip side, all three groups highlighted good health and life expectancy as a reason to continue surveillance.

PCP: Once in a while, you might have somebody who’s over 75, who’s super healthy, and if you had to predict... mortality, you would say that it would be reasonable for them to continue surveillance.

All groups also viewed GI recommendations, mostly in the form of the GI colonoscopy report, as a key influence to continue, with GIs mentioning size and severity of polyps as an influence on their recommendations.

Patient age was a theme across all three groups and appeared to both promote and hinder considerations for stopping surveillance. PCPs often cited 75 as the age to start conversations related to whether to continue while patients and GIs more often mentioned 80 or above.

PCP: So that usually happens around the age 75, and it’s a little bit their [patients], how they think about, how they view the possibility of having cancer is one factor. Their thinking about the risk and inconvenience of colonoscopy and the potential benefit of finding cancer against their projected life expectancy. And also explain to them that from polyps to cancer, it takes a long time… So if they’re 75 or older, they have to think of how they think about their longevity and whether they want to undergo a procedure that could benefit them, but that also has to carry some small risk.

Patient: I’m 76, so I figure in the next 10 years, that’s okay, I can get them. I think... When I’m 85 or 90, I don’t know that I’ll get them anymore. I mean, I’ve thought about this. It feels as though at some point, that if it’s cancer it’ll be slow enough that I’d probably won’t want an operation.

GI: We don’t have any strict age criteria per se. 85 is kind of our cutoff.

While PCPs and GIs cited professional guidelines, these may have variable influence for considering stopping surveillance.

GI: We practice based on guidelines, but everything is individualized. The guideline doesn’t tell you, “Well, this patient has these multiple comorbidities. They’re going to say yes or no.” You have to practice within the guideline, but it’s a guideline. It tells you what you should do, but you can modify it based on the presenting situation and patients.

Themes in Communication and Roles

Ten themes emerged in communication and roles. Considering those that promoted stopping surveillance, all three groups expressed a willingness to have conversations with each other about stopping and felt that PCPs were in a good position to advise patients about stopping as they “know” patients best (e.g., better personal relationship, knowing overall health).

Patient: My PCP knows me, knows my history, and knows me better. I’ve been with this doctor now 10 years since we moved here. I would want to get her perspective; it’s not that it would override the gastroenterologist’s. It’s just I would like to get her perspective as well, so that I can make a good decision.

PCP: So, I’m their primary care doctor, I’m not just a gastroenterologist. So, for me, I think knowing your patient, having a relationship, knowing what their goals are, knowing what their risk factors are, and knowing what they’re going through in life is very, very important.

PCPs and GIs generally suggested that PCPs’ role in advising patients about surveillance increased as patients grow older or develop new health conditions. Some GIs described this as deferring to the PCP regarding the patient stopping or continuing surveillance colonoscopies.

GI-A: They see the patient a couple of times a year and they know how they’re doing, how…they’re functioning…ability to cope with the day in and day out stresses of life and, and medical care. So, yeah, I’m pretty deferential to the patient and the primary care physician.

GI-B: If I see that they’re going to be reaching that age with their next procedure due date, then I actually put it into the letter and talk to the patient about it that you’re going to be advanced age, so you need to have a discussion with your primary care doctor at that point about your overall health status and make that decision.

Although PCPs and GIs appeared to respect each other’s roles around surveillance and felt able to reach out with questions or concerns, both groups described this as a rare occurrence likely resulting in continuing surveillance more often than not.

In terms of communication with patients, both PCPs and GIs felt comfortable having conversations about stopping surveillance, with PCPs bringing up patient preferences more often. At the same time, both groups acknowledged it could be a “delicate” discussion particularly in relation to age and life expectancy.

GI: Really, it’s a difficult area to talk about because it has a lot to do with mortality. What you’re really saying to somebody is, well, you’re going to die of something else, so let’s not bother with colonoscopy. But you can’t really say that because that doesn’t go over well, but that’s kind of what you’re saying. I think it sort of depends. Some patients take it as “great, I don’t need another colonoscopy.” Others take it as, well, “you’re not taking care of me because I’m too old,” so it’s a pretty delicate topic.

In the themes that appear to promote continuation of surveillance, four of the five were patient-specific, including patients feeling they are “supposed” to continue to prevent colon cancer, patients having variable understanding and education about polyps and colon cancer risk, and questioning reasons to stop, with some preferring switching to a less invasive test or delaying a colonoscopy versus stopping altogether.

Patient: I guess if there were valid reasons, I could accept it, but I’d want to know what those reasons are.

Themes Related to Systems

We identified five main themes related to system-level processes with two that appeared to promote stopping surveillance and three that did not. PCPs and GIs both noted that PCPs have more opportunities to discuss surveillance given more frequent visits and time during visits. Conversely, patients and GIs noted that GIs do not have opportune times to really discuss options given that interactions usually take place right after colonoscopies for a short period and when patients might still feel effects of colonoscopy sedation.

GIs also noted other processes that promote continued surveillance such as automated scheduling of subsequent surveillance colonoscopies. While a few GIs described making a note in the scheduling system to check on the patient’s status before scheduling if they had concerns with the patient’s health or that they were sometimes notified of a change in patient health status by another healthcare team member, this was not systematic or regularly done.

GI: I just say follow up in five years. Somehow that magically happens, and I don’t know how. Somebody puts that into the scheduling system.

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