General practitioners' perspectives on Direct Access Colonoscopy services in New South Wales: a mixed-methods study...

The aim of this study was to explore experiences of general practitioners (GPs) when referring patients with positive bowel cancer screening tests for colonoscopy, and identify enablers of and barriers to increasing referrals to public nurse-led Direct Access Colonoscopy (DAC) services in New South Wales, Australia.

A mixed-methods study was undertaken, with the design, analysis and interpretation informed by implementation science frameworks (COM-B and Theoretical Domains Framework). The quantitative component included an online survey of GPs in July 2024, recruited through primary health care networks. Survey participants could opt in for a follow-up semi-structured online interview. Descriptive statistics were produced with the quantitative data, categorised by general practice setting and size. Qualitative data were analysed deductively using theoretical frameworks.

A total of 71 GPs completed the survey, and 18 of those participated in an interview. Ninety per cent of survey participants were located in an area with a DAC service, but only 56% of these GPs were aware of the service (n = 51). All but two of the GPs who were aware of DAC had referred a patient to DAC in the previous 12 months (n = 34, 48%). The top three considerations for GPs when referring patients for a colonoscopy following a positive screening test were: average wait time for the procedure, patient finances and/or insurance, and patient and/or service location. Key factors influencing referral practices were knowledge gaps, unclear eligibility criteria, and lack of systemic prompts for referral. Although DAC was valued for providing timely, cost-free access to colonoscopy, some GPs preferred private referrals because these were more timely and less burdensome for patients. GPs expressed concerns about specialist oversight and continuity of care, which led some to view DAC as an inferior referral pathway.

To improve DAC services and strengthen trust in referring to DAC, GPs suggested increased communications about DAC to primary care; clear referral criteria, transparent wait times and simplified referral tools; statewide DAC service provision; clarification of specialist oversight and follow-up of high-risk patients; and targeted messaging about the DAC pathway using peer persuasion through professional networks.