BACKGROUND: Developing effective programs to promote colorectal cancer (CRC) screening requires understanding of the effect of healthcare system factors on access to screening and adherence to guidelines. METHODS: This study assessed the role of insurance status, type of plan, the frequency of preventive health visits, and provider recommendation on utilization of CRC screening tests using a cross-sectional, random-digit-dial survey of 1002 Massachusetts residents aged > or =50. RESULTS: A broad definition of CRC screening status included colonoscopy or barium enema (screening or diagnostic) within 10 years, flexible sigmoidoscopy (FSIG) within 5 years, and fecal occult blood testing (FOBT) in the past year as options; 51.7% of subjects aged 50 to 64 and 61.5% of older subjects were current. The uninsured had the lowest current testing rate. Among insured participants, type of insurance had little impact on CRC testing; older subjects enrolled in HMOs had marginally higher rates, although not statistically significant. Increased frequency of preventive health visits and ever receiving a physician's recommendation for FSIG or ever receiving FOBT cards were associated with higher rates of CRC screening among both age groups. CONCLUSIONS: Even when broad criteria are used to define current CRC screening status, a substantial proportion of the age-eligible population remains underscreened. Obtaining regular preventive care and receiving a physician's recommendation for screening appear to be potent facilitators of screening that should be considered in designing promotional efforts.

CONTEXT: Professional organizations have published guidelines for colorectal cancer screening. Defining which patients are currently, or should be, screened is an important clinical and public health issue. OBJECTIVE: To document the prevalence of colorectal cancer screening and profile the tests patients have had. DESIGN/POPULATION: A random-digit telephone survey of Massachusetts adults, 50 years of age and older. OUTCOME MEASURES: Percentage of persons ever and currently tested by fecal occult blood tests, flexible sigmoidoscopy, barium enema, colonoscopy, or some combination of these tests. RESULTS: Sixty-five percent of those contacted agreed to the telephone interview. Approximately 29% of the 1119 respondents had never had any currently accepted test, including 10% who reported having only a fecal occult blood test done in a provider's office and 19% who reported having no tests. At least 51% were currently tested by one or more tests for screening, diagnosis, or both. Another 10% were possibly current by colonoscopy or barium enema, both of which can be ordered for screening but are more commonly used to evaluate a problem, such as rectal bleeding, or for surveillance after identification of a polyp or other abnormality. An additional 11% had been tested at some point but were not current according to guidelines. CONCLUSIONS: Accurate assessment of rates of colorectal cancer screening is complex because of the multiple acceptable screening methods, the fact that patients may be tested for screening or diagnostic purposes, and the lack of adequate systems for tracking such testing. For accurate measurement, all methods must be assessed regardless of whether tests were ordered for screening, diagnosis, or surveillance.