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Hahn EE, Munoz-Plaza CE, Jensen CD, Ghai NR, Pak K, Amundsen BI, Contreras R, Cannizzaro N, Chubak J, Green BB, Skinner CS, Halm EA, Schottinger JE, Levin TR. Patterns of Care Following a Positive Fecal Blood Test for Colorectal Cancer: A Mixed Methods Study. J Gen Intern Med 2024:10.1007/s11606-024-08764-0. [PMID: 38771535 DOI: 10.1007/s11606-024-08764-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 04/02/2024] [Indexed: 05/22/2024]
Abstract
BACKGROUND/OBJECTIVE Multilevel barriers to colonoscopy after a positive fecal blood test for colorectal cancer (CRC) are well-documented. A less-explored barrier to appropriate follow-up is repeat fecal testing after a positive test. We investigated this phenomenon using mixed methods. DESIGN This sequential mixed methods study included quantitative data from a large cohort of patients 50-89 years from four healthcare systems with a positive fecal test 2010-2018 and qualitative data from interviews with physicians and patients. MAIN MEASURES Logistic regression was used to evaluate whether repeat testing was associated with failure to complete subsequent colonoscopy and to identify factors associated with repeat testing. Interviews were coded and analyzed to explore reasons for repeat testing. KEY RESULTS A total of 316,443 patients had a positive fecal test. Within 1 year, 76.3% received a colonoscopy without repeat fecal testing, 3% repeated testing and then received a colonoscopy, 4.4% repeated testing without colonoscopy, and 16.3% did nothing. Among repeat testers (7.4% of total cohort, N = 23,312), 59% did not receive a colonoscopy within 1 year. In adjusted models, those with an initial positive test followed by a negative second test were significantly less likely to receive colonoscopy than those with two successive positive tests (OR 0.37, 95% CI 0.35-0.40). Older age (65-75 vs. 50-64 years: OR 1.37, 95% CI 1.33-1.41) and higher comorbidity score (≥ 4 vs. 0: OR 1.75, 95% CI 1.67-1.83) were significantly associated with repeat testing compared to those who received colonoscopy without repeat tests. Qualitative interview data revealed reasons underlying repeat testing, including colonoscopy avoidance, bargaining, and disbelief of positive results. CONCLUSIONS Among patients in this cohort, 7.4% repeated fecal testing after an initial positive test. Of those, over half did not go on to receive a colonoscopy within 1 year. Efforts to improve CRC screening must address repeat fecal testing after a positive test as a barrier to completing colonoscopy.
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Affiliation(s)
- Erin E Hahn
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA.
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, USA.
| | - Corrine E Munoz-Plaza
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | | | - Nirupa R Ghai
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Katherine Pak
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Britta I Amundsen
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Richard Contreras
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Nancy Cannizzaro
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Jessica Chubak
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - Beverly B Green
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - Celette Sugg Skinner
- Peter O'Donnell Jr. School of Public Health, University of Texas Southwestern Medical Center, Dallas, TX, USA
- Harold C. Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Ethan A Halm
- Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Joanne E Schottinger
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, USA
| | - Theodore R Levin
- Kaiser Permanente Division of Research, Oakland, CA, USA
- Kaiser Permanente Medical Center, Walnut Creek, CA, USA
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Rasmussen SL, Torp-Pedersen C, Gotschalck KA, Thorlacius-Ussing O. The effect of antithrombotic treatment on the fecal immunochemical test for colorectal cancer screening: a nationwide cross-sectional study. Endoscopy 2023; 55:444-455. [PMID: 36702131 DOI: 10.1055/a-1992-5598] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND : Screening for colorectal cancer (CRC) using the fecal immunochemical test (FIT) has been widely adopted. The use of antithrombotic treatment is increasing in the Western world. This study aimed to assess the effects of antithrombotic treatment on the FIT-based Danish national screening program for CRC. METHODS : This was a cross-sectional study of all individuals returning a FIT from 2014 until 2016. The effect of antithrombotic treatment on FIT positivity and the positive predictive value (PPV) were assessed using proportions and multivariable Poisson regression. RESULTS : Of 884 036 invited individuals, we identified 551 570 participants. A positive FIT was observed in 9052 of 77 007 individuals (11.8 %) receiving antithrombotic treatment compared with 28 387 of 474 587 individuals (6.0 %) receiving no treatment. The adjusted relative risk (RR) for a positive FIT was 1.59 (95 %CI 1.56-1.63) for any treatment. Nonvitamin K oral anticoagulants (NOACs) were associated with the largest increase in FIT positivity (adjusted RR 2.40, 95 %CI 2.48-2.54). The proportion of CRC detected at colonoscopy was slightly lower among patients on antithrombotic treatment (6.0 %, 95 %CI 5.5 %-6.6 %) than among treatment-naïve patients (6.4 %, 95 %CI 6.1 %-6.7 %). The PPV for CRC or high risk adenomas was decreased nearly twofold in patients treated with NOAC (adjusted RR 0.58, 95 %CI 0.51-0.66]). CONCLUSION : Antithrombotic treatment was associated with a decreased PPV in FIT-based CRC screening.
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Affiliation(s)
- Simon Ladefoged Rasmussen
- Department of Gastrointestinal Surgery, Aalborg University Hospital, Aalborg, Denmark.,Clinical Cancer Research Center, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Christian Torp-Pedersen
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Investigation and Cardiology, Nordsjaellands Hospital Hillerød, Denmark
| | | | - Ole Thorlacius-Ussing
- Department of Gastrointestinal Surgery, Aalborg University Hospital, Aalborg, Denmark.,Clinical Cancer Research Center, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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3
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Khoong EC, Rivadeneira NA, Pacca L, Schillinger D, Lown D, Babaria P, Gupta N, Pramanik R, Tran H, Whitezell T, Somsouk M, Sarkar U. Extent of Follow-Up on Abnormal Cancer Screening in Multiple California Public Hospital Systems: A Retrospective Review. J Gen Intern Med 2023; 38:21-29. [PMID: 35641722 PMCID: PMC9849534 DOI: 10.1007/s11606-022-07657-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 05/03/2022] [Indexed: 01/22/2023]
Abstract
BACKGROUND Inequitable follow-up of abnormal cancer screening tests may contribute to racial/ethnic disparities in colon and breast cancer outcomes. However, few multi-site studies have examined follow-up of abnormal cancer screening tests and it is unknown if racial/ethnic disparities exist. OBJECTIVE This report describes patterns of performance on follow-up of abnormal colon and breast cancer screening tests and explores the extent to which racial/ethnic disparities exist in public hospital systems. DESIGN We conducted a retrospective cohort study using data from five California public hospital systems. We used multivariable robust Poisson regression analyses to examine whether patient-level factors or site predicted receipt of follow-up test. MAIN MEASURES Using data from five public hospital systems between July 2015 and June 2017, we assessed follow-up of two screening results: (1) colonoscopy after positive fecal immunochemical tests (FIT) and (2) tissue biopsy within 21 days after a BIRADS 4/5 mammogram. KEY RESULTS Of 4132 abnormal FITs, 1736 (42%) received a follow-up colonoscopy. Older age, Medicaid insurance, lack of insurance, English language, and site were negatively associated with follow-up colonoscopy, while Hispanic ethnicity and Asian race were positively associated with follow-up colonoscopy. Of 1702 BIRADS 4/5 mammograms, 1082 (64%) received a timely biopsy; only site was associated with timely follow-up biopsy. CONCLUSION Despite the vulnerabilities of public-hospital-system patients, follow-up of abnormal cancer screening tests occurs at rates similar to that of patients in other healthcare settings, with colon cancer screening test follow-up occurring at lower rates than follow-up of breast cancer screening tests. Site-level factors have larger, more consistent impact on follow-up rates than patient sociodemographic traits. Resources are needed to identify health system-level factors, such as test follow-up processes or data infrastructure, that improve abnormal cancer screening test follow-up so that effective health system-level interventions can be evaluated and disseminated.
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Affiliation(s)
- Elaine C Khoong
- Division of General Internal Medicine at Zuckerberg San Francisco General Hospital, Department of Medicine, University of California San Francisco, San Francisco, CA, USA. .,UCSF Center for Vulnerable Populations at Zuckerberg San Francisco General Hospital, San Francisco, CA, USA.
| | - Natalie A Rivadeneira
- Division of General Internal Medicine at Zuckerberg San Francisco General Hospital, Department of Medicine, University of California San Francisco, San Francisco, CA, USA.,UCSF Center for Vulnerable Populations at Zuckerberg San Francisco General Hospital, San Francisco, CA, USA
| | - Lucia Pacca
- Division of General Internal Medicine at Zuckerberg San Francisco General Hospital, Department of Medicine, University of California San Francisco, San Francisco, CA, USA.,UCSF Center for Vulnerable Populations at Zuckerberg San Francisco General Hospital, San Francisco, CA, USA
| | - Dean Schillinger
- Division of General Internal Medicine at Zuckerberg San Francisco General Hospital, Department of Medicine, University of California San Francisco, San Francisco, CA, USA.,UCSF Center for Vulnerable Populations at Zuckerberg San Francisco General Hospital, San Francisco, CA, USA
| | - David Lown
- California Health Care Safety Net Institute, Oakland, CA, USA
| | - Palav Babaria
- Division of General Internal Medicine at Zuckerberg San Francisco General Hospital, Department of Medicine, University of California San Francisco, San Francisco, CA, USA.,Alameda Health System, Oakland, CA, USA
| | | | - Rajiv Pramanik
- Office of Informatics & Technology and Department of Emergency Medicine, Contra Costa Health Services, Martinez, CA, USA
| | - Helen Tran
- Department of Family Medicine, Charles R. Drew University College of Medicine, Los Angeles, CA, USA.,Department of Health Services at Los Angeles County, Los Angeles, CA, USA
| | | | - Ma Somsouk
- UCSF Center for Vulnerable Populations at Zuckerberg San Francisco General Hospital, San Francisco, CA, USA.,Division of Gastroenterology, Department of Medicine, UCSF, San Francisco, CA, USA
| | - Urmimala Sarkar
- Division of General Internal Medicine at Zuckerberg San Francisco General Hospital, Department of Medicine, University of California San Francisco, San Francisco, CA, USA.,UCSF Center for Vulnerable Populations at Zuckerberg San Francisco General Hospital, San Francisco, CA, USA
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Effect of Chronic Comorbidities on Follow-up Colonoscopy After Positive Colorectal Cancer Screening Results: A Population-Based Cohort Study. Am J Gastroenterol 2022; 117:1137-1145. [PMID: 35333781 DOI: 10.14309/ajg.0000000000001742] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 03/18/2022] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Fecal occult blood tests (FOBTs) are colorectal cancer screening tests used to identify individuals requiring further investigation with colonoscopy. Delayed colonoscopy after positive FOBT (FOBT+) is associated with poorer cancer outcomes. We assessed the effect of comorbidity on colonoscopy receipt within 12 months after FOBT+. METHODS Population-based healthcare databases from Ontario, Canada, were linked to assemble a cohort of 50-74-year-old individuals with FOBT+ results between 2008 and 2017. The associations between comorbidities and colonoscopy receipt within 12 months after FOBT+ were examined using multivariable cause-specific hazard regression models. RESULTS Of 168,701 individuals with FOBT+, 80.5% received colonoscopy within 12 months. In multivariable models, renal failure (hazard ratio [HR] 0.71, 95% confidence interval [CI] 0.62-0.82), heart failure (HR 0.77, CI 0.75-0.80), and serious mental illness (HR 0.88, CI 0.85-0.92) were associated with the lowest colonoscopy rates, compared with not having each condition. The number of medical conditions was inversely associated with colonoscopy uptake (≥4 vs 0: HR 0.64, CI 0.58-0.69; 3 vs 0: HR 0.75, CI 0.72-0.78; and 2 vs 0: HR 0.87, CI 0.85-0.89). Having both medical and mental health conditions was associated with a lower colonoscopy uptake relative to no comorbidity (HR 0.88, CI 0.87-0.90). DISCUSSION Persons with medical and mental health conditions had lower colonoscopy rates after FOBT+ than those without these conditions. Better strategies are needed to optimize colorectal cancer screening and follow-up in individuals with comorbidities.
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Yang Y, Huang J, Wu W, Luu HN, Moy FM, Tan S, Fu J, Ying T, Withers M, Hung DT, Mao D, Chen S, Wong MCS, Xu W. A global view of adherence to colonoscopy follow-up in cascade screening of colorectal cancer. Eur J Cancer Care (Engl) 2022; 31:e13577. [PMID: 35315165 DOI: 10.1111/ecc.13577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Revised: 01/11/2022] [Accepted: 03/11/2022] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To overview the colonoscopy adherence in cascade screening of colorectal cancer (CRC) and evaluate potential influence of the initial tests based on an ecological evaluation. METHODS The performance of the initial screening tests and adherence to subsequent colonoscopy were extracted from relevant studies published up to 16 October 2020. The age-standardised incidence (ASRi) of CRC in populations in the year of screening was derived from the Cancer Statistics. RESULTS One hundred sixty-six observational studies and 60 experimental studies were identified. Most studies applied cascade screening with faecal occult blood tests (FOBTs) as an initial test. The adherence to colonoscopy varied greatly across populations by continents, gross national income and type of initial tests, with a median (interquartile range) of 79.8% (63.1%-87.8%) in observational studies and 82.1% (66.7%-90.4%) in randomised trials. The adherence was positively correlated with the ASRi of CRC (r = 0.145, p = 0.023) and positive predictive value (PPV) of the initial tests (r = 0.206, p = 0.002) in observational studies and correlated with ASRi of CRC (r = 0.309, p = 0.002) and sensitivity of the initial tests (r = -0.704, p = 0.003) in experimental studies. CONCLUSIONS Adherence to colonoscopy varies greatly across populations and is related with performance of the initial tests, indicating the importance to select appropriate initial tests.
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Affiliation(s)
- Yihui Yang
- Global Health Institute, School of Public Health, Fudan University, Shanghai, China
| | - Junjie Huang
- J.C. School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
| | - Weimiao Wu
- Global Health Institute, School of Public Health, Fudan University, Shanghai, China
| | - Hung N Luu
- Division of Cancer Control and Population Sciences, UPMC Hillman Cancer Center, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Foong-Ming Moy
- Julius Centre, Department of Social and Preventive Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Songsong Tan
- Global Health Institute, School of Public Health, Fudan University, Shanghai, China
| | - Jiongxing Fu
- Global Health Institute, School of Public Health, Fudan University, Shanghai, China
| | - Tao Ying
- Global Health Institute, School of Public Health, Fudan University, Shanghai, China
| | - Mellissa Withers
- Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Dang The Hung
- Laboratory Center, Hanoi University of Public Health, Hanoi, Vietnam
| | - Dandan Mao
- Global Health Institute, School of Public Health, Fudan University, Shanghai, China
| | - Sikun Chen
- Global Health Institute, School of Public Health, Fudan University, Shanghai, China
| | - Martin C S Wong
- J.C. School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
| | - Wanghong Xu
- Global Health Institute, School of Public Health, Fudan University, Shanghai, China
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Zorzi M, Battagello J, Selby K, Capodaglio G, Baracco S, Rizzato S, Chinellato E, Guzzinati S, Rugge M. Non-compliance with colonoscopy after a positive faecal immunochemical test doubles the risk of dying from colorectal cancer. Gut 2022; 71:561-567. [PMID: 33789965 PMCID: PMC8862019 DOI: 10.1136/gutjnl-2020-322192] [Citation(s) in RCA: 36] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 03/15/2021] [Accepted: 03/16/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND The risk of colorectal cancer (CRC) among subjects with a positive faecal immunochemical test (FIT) who do not undergo a colonoscopy is unknown. We estimated whether non-compliance with colonoscopy after a positive FIT is associated with increased CRC incidence and mortality. METHODS The FIT-based CRC screening programme in the Veneto region (Italy) invited persons aged 50 to 69 years with a positive FIT (>20 µg Hb/g faeces) for diagnostic colonoscopy at an endoscopic referral centre. In this retrospective cohort study, we compared the 10-year cumulative CRC incidence and mortality among FIT positives who completed a diagnostic colonoscopy within the programme (compliers) and those who did not (non-compliers), using the Kaplan-Meier estimator and Cox-Aalen models. RESULTS Some 88 013 patients who were FIT positive complied with colonoscopy (males: 56.1%; aged 50-59 years: 49.1%) while 23 410 did not (males: 54.6%; aged 50-59 years: 44.9%).The 10-year cumulative incidence of CRC was 44.7 per 1000 (95% CI, 43.1 to 46.3) among colonoscopy compliers and 54.3 per 1000 (95% CI, 49.9 to 58.7) in non-compliers, while the cumulative mortality for CRC was 6.8 per 1000 (95% CI, 5.9 to 7.6) and 16.0 per 1000 (95% CI, 13.1 to 18.9), respectively. The risk of dying of CRC among non-compliers was 103% higher than among compliers (adjusted HR, 2.03; 95% CI, 1.68 to 2.44). CONCLUSION The excess risk of CRC death among those not completing colonoscopy after a positive faecal occult blood test should prompt screening programmes to adopt effective interventions to increase compliance in this high-risk population.
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Affiliation(s)
- Manuel Zorzi
- Veneto Tumour Registry, Azienda Zero, Padova, Italy
| | | | - Kevin Selby
- Center for Primary Care and Public Health (Unisanté), University of Lausanne, Lausanne, Switzerland
| | - Giulia Capodaglio
- Screening and Health Impact Assessment Unit, Azienda Zero, Padova, Italy
| | | | | | | | | | - Massimo Rugge
- Veneto Tumour Registry, Azienda Zero, Padova, Italy
- Department of Medicine - DIMED, University of Padova, Padova, Italy
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Current Trends and Predictors of Case Outcomes for Malpractice in Colonoscopy in the United States. J Clin Gastroenterol 2022; 56:49-54. [PMID: 33337638 DOI: 10.1097/mcg.0000000000001471] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 10/26/2020] [Indexed: 12/10/2022]
Abstract
BACKGROUND Over 14 million colonoscopies are performed annually, and this procedure remains the largest contributor to malpractice claims against gastroenterologists. The aim of this study was to evaluate reasons for litigation and predictors of case outcomes. MATERIALS AND METHODS Cases related to colonoscopy were reviewed within the Westlaw legal database. Patient demographics, reasons for litigation, case payouts, and verdicts were assessed. Multivariate regression was used to determine predictors of defendant verdicts. RESULTS A total of 305 cases were included from years 1980 to 2017. Average patient age was 54.9 years (range, 4 to 93) and 52.8% of patients were female. Juries returned defendant and plaintiff verdicts in 51.8% and 25.2% of cases, respectively, and median payout was $995,000. Top reasons for litigation included delay in treatment (65.9%) and diagnosis (65.6%), procedural error (44.3%), and failure to refer (25.6%). Gastroenterologists were defendants in 71% of cases, followed by primary care (32.2%) and surgeons (14.8%). Cases citing informed consent predicted defendant verdict (odds ratio, 4.05; 95% confidence interval, 1.90-9.45) while medication error predicted plaintiff verdict (odds ratio, 0.18; 95% confidence interval, 0.04-0.59). Delay in diagnosis (P=0.060) and failure to refer (P=0.074) trended toward plaintiff verdict but did not reach significance. Most represented states were New York (21.0%), California (13.4%), Pennsylvania (13.1%), Massachusetts (12.5%). CONCLUSIONS Malpractice related to colonoscopy remains a significant and has geographic variability. Errors related to sedation predicted plaintiff verdict and may represent a target to reduce litigation. Primary care physicians and surgeons were frequently cited codefendants, underscoring the significance of interdisciplinary care for colonoscopy.
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8
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Hoeck S, De Schutter H, Van Hal G. Why do participants in the Flemish colorectal cancer screening program not undergo a diagnostic colonoscopy after a positive fecal immunochemical test? Acta Clin Belg 2021; 77:760-766. [PMID: 34530695 DOI: 10.1080/17843286.2021.1980675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Sarah Hoeck
- Social Epidemiology and Health Policy, University of Antwerp, Antwerpen, Belgium
- Centre for Cancer Detection, Bruges, Belgium
| | | | - Guido Van Hal
- Social Epidemiology and Health Policy, University of Antwerp, Antwerpen, Belgium
- Centre for Cancer Detection, Bruges, Belgium
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9
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Zorzi M, Rugge M. United we win: Pushing for follow up after a positive faecal immunochemical test. Dig Liver Dis 2021; 53:1058. [PMID: 34083154 DOI: 10.1016/j.dld.2021.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 05/04/2021] [Indexed: 12/11/2022]
Affiliation(s)
- Manuel Zorzi
- Veneto Tumour Registry, Azienda Zero, Padova, Italy.
| | - Massimo Rugge
- Veneto Tumour Registry, Azienda Zero, Padova, Italy; Department of Medicine DIMED Pathology and Cytopathology Unit, University of Padova, Padova, Italy
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10
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Disparities in Colorectal Cancer Screening Practices in a Midwest Urban Safety-Net Healthcare System. Dig Dis Sci 2021; 66:2585-2594. [PMID: 32816217 DOI: 10.1007/s10620-020-06545-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 08/06/2020] [Indexed: 01/05/2023]
Abstract
AIMS Although colorectal cancer screening (CRC) using stool-based test is well-studied, evidence on fecal immunochemical test (FIT) patterns in a safety-net healthcare system utilizing opportunistic screening is limited. We studied the FIT completion rates and adenoma detection rate (ADR) of positive FIT-colonoscopy (FIT-C) in an urban safety-net system. METHODS We performed a retrospective cross-sectional chart review on individuals ≥ 50 years who underwent CRC screening using FIT or screening colonoscopy, 09/01/2017-08/30/2018. Demographic differences in FIT completion were studied; ADR of FIT-C was compared to that of screening colonoscopy. RESULTS Among 13,427 individuals with FIT ordered, 7248 (54%) completed the stool test and 230 (48%) followed up a positive FIT with colonoscopy. Increasing age (OR 1.01, CI 1.01-1.02), non-Hispanic Blacks (OR 0.87, CI 0.80-0.95, p = 0.002), current smokers (OR 0.84, CI 0.77-0.92, p < 0.0001), those with Medicaid (OR 0.86, CI 0.77-0.96, p = 0.006), commercial insurance (OR 0.85, CI 0.78-0.94, p = 0.002), CCI score ≥ 3 (OR 0.82, CI 0.74-0.91, p < 0.0001), orders by family medicine providers (OR 0.87, CI 0.81-0.94, p < 0.0001) were associated with lower completion of stool test. Individuals from low median household income cities had lower follow-up of positive FIT, OR 0.43, CI 0.21-0.86, p = 0.017. ADR of FIT-C was higher than that of screening colonoscopy. CONCLUSION Adherence to CRC screening is low in safety-net systems employing opportunistic screening. Understanding demographic differences may allow providers to formulate targeted strategies in high-risk vulnerable groups.
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11
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Gluskin AB, Dueker JM, Khalid A. High Rate of Inappropriate Fecal Immunochemical Testing at a Large Veterans Affairs Health Care System. Fed Pract 2021; 38:270-275. [PMID: 34733074 PMCID: PMC8560050 DOI: 10.12788/fp.0142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Colonoscopies and fecal immunochemical tests (FITs) are the preferred modalities for colorectal cancer (CRC) screening. In addition to proper patient selection, appropriate fecal immunochemical testing requires that negative tests be repeated annually, positive tests lead to a diagnostic colonoscopy, and FIT not be performed within 5 years of a colonoscopy with adequate bowel preparation. We sought to study the frequency of inappropriate FITs at the Veterans Affairs Pittsburgh Health Care System in Pennsylvania. METHODS A retrospective quality assurance study was undertaken of veterans undergoing FIT in a 3-year period (2015-2017). We calculated the rate of a negative initial FIT in 2015/2016 followed by a second FIT in 2016/2017 in a random selection of veterans (3% SE, 95% CI). Demographics were compared in an equal random number of veterans that did and did not have a follow-up FIT (5% SE, 95% CI of all negative FIT). We also calculated the rate of completing colonoscopy following a positive FIT in a random selection of veterans (3% SE, 95% CI). Finally, we investigated use of FIT following a colonoscopy for all veterans in the study period. RESULTS A total of 6,766 FITs were performed; 4,391 unique veterans had at least 1 negative FIT, and 709 unique veterans had a positive FIT. Of 1,742 veterans with at least 1 negative FIT, 870 were eligible for repeat testing during the study period, and only 543 (62.4%) underwent at least 2 FITs. There was no significant demographic difference in veterans that had only 1 or at least 2 FITs. Of 410 veterans with a positive FIT, 113 (27.5%) did not undergo a subsequent colonoscopy within 1 year due to patient refusal, or failure to schedule or keep a colonoscopy appointment. Of 832 veterans who had both a FIT and colonoscopy in the interval, 108 veterans underwent colonoscopy with a subsequent FIT (1.6% of total FITs performed). Of these, 95 (88%) were judged to be inappropriate. Thirteen instances of FIT following colonoscopy were appropriate based on patient preference to undergo fecal immunochemical testing for CRC screening modality after undergoing colonoscopy with an inadequate bowel preparation. CONCLUSIONS Veterans underwent inappropriate testing due to failure to undergo serial FIT after a negative result (37.6%), failure to complete colonoscopy following a positive FIT (27.5%), and undergoing inappropriate FIT following a recent colonoscopy (88%). Efforts are still required to improve both patient and provider education and adherence to appropriate fecal immunochemical testing and CRC screening guidelines.
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Affiliation(s)
- Adam B Gluskin
- is a Gastroenterology Fellow and and are Gastroenterologists at Veterans Affairs Pittsburgh Health Care System and the University of Pittsburgh Medical Center in Pennsylvania
| | - Jeffrey M Dueker
- is a Gastroenterology Fellow and and are Gastroenterologists at Veterans Affairs Pittsburgh Health Care System and the University of Pittsburgh Medical Center in Pennsylvania
| | - Asif Khalid
- is a Gastroenterology Fellow and and are Gastroenterologists at Veterans Affairs Pittsburgh Health Care System and the University of Pittsburgh Medical Center in Pennsylvania
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Kim YJ, Shim JI, Park E, Kang M, Kang S, Lee J, Tchoe HJ, Kong KA, Kim DH, Kim BC, Choi KS, Moon CM. Adherence to follow-up examination after positive fecal occult blood test results affects colorectal cancer mortality: A Korea population-based cohort study. Dig Liver Dis 2021; 53:631-638. [PMID: 33676856 DOI: 10.1016/j.dld.2021.02.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Revised: 02/01/2021] [Accepted: 02/02/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND The impact of adherence to follow-up examination after a fecal occult blood test (FOBT) remains ill-defined. AIM To evaluate the impact of adherence to the follow-up examination on clinical outcomes in individuals with positive FOBT results. METHODS This was a retrospective cohort study involving Korean individuals aged 50 years or older who participated in the National Cancer Screening Program for CRC from 2009 to 2010. Individuals who underwent a confirmative examination within a year after positive FOBT results were included in compliant group, and those who did not were included in non-compliant group. The incidence and stage of CRC, and 5-year survival were compared between two groups. RESULTS 5,914 were diagnosed with CRC in the compliant group and 2,973 in the non-compliant group. The proportion of advanced-stage CRC was significantly higher in the non-compliant group (localized CRC 44.6% vs. 36.7% and distant CRC 8.7% vs. 12.5%, p< 0.0001). The survival probability within 5 years was 71.0% in the non-compliant group and 85.9% in the compliant group (hazard ratio 1.70, 95% CI, 1.52-1.90, p< 0.001). CONCLUSION Individuals who underwent follow-up examination 1 year or more after positive FOBT had a lower survival rate compared with that in those who underwent examination within 1 year.
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Affiliation(s)
- Yu Jin Kim
- Department of Gastroenterology, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, South Korea
| | - Jeong-Im Shim
- National Evidence-based Healthcare Collaborating Agency, South Korea
| | - Eunjung Park
- National Evidence-based Healthcare Collaborating Agency, South Korea.
| | - Minjoo Kang
- National Evidence-based Healthcare Collaborating Agency, South Korea
| | - Sinhee Kang
- National Evidence-based Healthcare Collaborating Agency, South Korea
| | - Jessie Lee
- National Evidence-based Healthcare Collaborating Agency, South Korea
| | - Ha Jin Tchoe
- National Evidence-based Healthcare Collaborating Agency, South Korea
| | - Kyeong Ae Kong
- Department of Preventive Medicine, College of Medicine, Ewha Womans University, South Korea
| | - Duk Hwan Kim
- Digestive Disease Center, Department of Internal Medicine, CHA University School of Medicine, South Korea
| | - Byung Chang Kim
- Center for Colorectal Cancer, Center for Cancer Prevention and Detection, Cancer Epidemiology Branch, Research Institute and Hospital, National Cancer Center, South Korea
| | - Kui Son Choi
- Department of Cancer Control and Population Health, Graduate School of Cancer Science and Policy, National Cancer Center, South Korea
| | - Chang Mo Moon
- Department of Internal Medicine, College of Medicine, Ewha Womans University, South Korea; Inflammation-Cancer Microenvironment Research Center, College of Medicine, Ewha Womans University, Seoul, South Korea.
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13
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Primary care clinicians' perceptions of colorectal cancer screening tests for older adults. Prev Med Rep 2021; 22:101369. [PMID: 33948426 PMCID: PMC8080529 DOI: 10.1016/j.pmedr.2021.101369] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 01/21/2021] [Accepted: 03/21/2021] [Indexed: 12/12/2022] Open
Abstract
How clinicians use stool tests for older adults (65+) is not well understood. Preferred in patients who are sicker and for whom guidelines do not recommend. Clinicians must better individualize the use of colorectal tests in older adults.
Colonoscopy is an effective screening test for colorectal cancer but is associated with significant risks and burdens, especially in older adults. Stool tests, which are more convenient, more accessible, and less invasive, can be important tools to improve screening. How clinicians make decisions about colonoscopy versus stool tests in older patients is not well-understood. We conducted semi-structured interviews with primary care clinicians throughout Maryland in 2018–2019 to examine how clinicians considered the use of stool tests for colorectal cancer screening in their older patients. Thirty clinicians from 21 clinics participated. The mean clinician age was 48.2 years. The majority were physicians (24/30) and women (16/30). Four major themes were identified using qualitative content analysis: (1) Stool test equivalency - although many clinicians still considered colonoscopy as the test of choice, some clinicians considered stool tests equivalent options for screening. (2) Reasons for recommending stool tests – clinicians reported preferentially using stool tests in sicker/older patients or patients who declined colonoscopy. (3) Stool test overuse – some clinicians reported recommending stool tests for patients for whom guidelines do not recommend any screening. (4) Barriers to use – perceived barriers to using stool tests included lack of familiarity, un-returned stool test kits, concern for accuracy, and concern about cost. In summary, clinicians reported preferentially using stool tests in sicker and older patients and mentioned examples of potential overuse. Additional studies are needed on how to better individualize the use of different colorectal screening tests in older patients.
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Implementing a multilevel intervention to accelerate colorectal cancer screening and follow-up in federally qualified health centers using a stepped wedge design: a study protocol. Implement Sci 2020; 15:96. [PMID: 33121536 PMCID: PMC7599111 DOI: 10.1186/s13012-020-01045-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 09/10/2020] [Indexed: 12/31/2022] Open
Abstract
Background Screening for colorectal cancer (CRC) not only detects disease early when treatment is more effective but also prevents cancer by finding and removing precancerous polyps. Because many of our nation’s most disadvantaged and vulnerable individuals obtain health care at federally qualified health centers, these centers play a significant role in increasing CRC screening among the most vulnerable populations. Furthermore, the full benefits of cancer screenings must include timely and appropriate follow-up of abnormal results. Thus, the purpose of this study is to implement a multilevel intervention to increase rates of CRC screening, follow-up, and referral-to-care in federally qualified health centers, as well as simultaneously to observe and to gather information on the implementation process to improve the adoption, implementation, and sustainment of the intervention. The multilevel intervention will target three different levels of influences: organization, provider, and individual. It will have multiple components, including provider and staff education, provider reminder, provider assessment and feedback, patient reminder, and patient navigation. Methods This study is a multilevel, three-phase, stepped wedge cluster randomized trial with four clusters of clinics from four different FQHC systems. In the first phase, there will be a 3-month waiting period during which no intervention components will be implemented. After the 3-month waiting period, we will randomize two clusters to cross from the control to the intervention and the remaining two clusters to follow 3 months later. All clusters will stay at the same phase for 9 months, followed by a 3-month transition period, and then cross over to the next phase. Discussion There is a pressing need to reduce disparities in CRC outcomes, especially among racial/ethnic minority populations and among populations who live in poverty. Single-level interventions are often insufficient to lead to sustainable changes. Multilevel interventions, which target two or more levels of changes, are needed to address multilevel contextual influences simultaneously. Multilevel interventions with multiple components will affect not only the desired outcomes but also each other. How to take advantage of multilevel interventions and how to implement such interventions and evaluate their effectiveness are the ultimate goals of this study. Trial registration This protocol is registered at clinicaltrials.gov (NCT04514341) on 14 August 2020.
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15
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Kaushal A, Stoffel ST, Kerrison R, von Wagner C. Preferences for different diagnostic modalities to follow up abnormal colorectal cancer screening results: a hypothetical vignette study. BMJ Open 2020; 10:e035264. [PMID: 32713846 PMCID: PMC7383951 DOI: 10.1136/bmjopen-2019-035264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES In England, a significant proportion of people who take part in the national bowel cancer screening programme (BCSP) and have a positive faecal occult blood test (FOBt) result, do not attend follow-up colonoscopy (CC). The aim of this study was to investigate differences in intended participation in a follow-up investigation by diagnostic modality offered including CC, CT colonography (CTC) or capsule endoscopy (CE). SETTING We performed a randomised online experiment with individuals who had previously completed an FOBt as part of the English BCSP. METHODS Participants (n=953) were randomly allocated to receive one of three online vignettes asking participants to imagine they had received an abnormal FOBt result, and that they had been invited for a follow-up test. The follow-up test offered was either: CC (n=346), CTC (n=302) or CE (n=305). Participants were then asked how likely they were to have their allocated test or if they refused, either of the other tests. Respondents were also asked to cite possible emotional and practical barriers to follow up testing. Multivariable logistic regression models were used to investigate intentions. RESULTS Intention to have the test was higher in the CTC group (96.7%) compared with the CC group (91.8%; OR 2.64; 95% CI 1.22 to 5.73). CTC was considered less 'off-putting' (OR 0.66, 95% CI 0.47 to 0.94) and less uncomfortable compared with CC (OR 0.51, 95% CI 0.34 to 0.77). For those who did not intend to have the test they were offered, CE (39.7%) or no investigation (34.5%) was preferable to CC (8.6%) or CTC (17.2%). CONCLUSIONS Alternative tests have the potential to increase attendance at diagnostic follow-up appointments.
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Affiliation(s)
- Aradhna Kaushal
- Research Department of Behavioural Science and Health, University College London, London, UK
| | - Sandro Tiziano Stoffel
- Research Department of Behavioural Science and Health, University College London, London, UK
- European Center of Pharmaceutical Medicine, University of Basel, Basel, Switzerland
| | - Robert Kerrison
- Research Department of Behavioural Science and Health, University College London, London, UK
| | - Christian von Wagner
- Research Department of Behavioural Science and Health, University College London, London, UK
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16
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Making FIT Count: Maximizing Appropriate Use of the Fecal Immunochemical Test for Colorectal Cancer Screening Programs. J Gen Intern Med 2020; 35:1870-1874. [PMID: 32128688 PMCID: PMC7280423 DOI: 10.1007/s11606-020-05728-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Accepted: 02/10/2020] [Indexed: 02/06/2023]
Abstract
Colorectal cancer (CRC) remains one of the most common and deadly malignancies despite advancements in screening, diagnostic capabilities, and treatment. The ability to detect and remove precancerous and cancerous lesions via screening has altered the epidemiology of the disease, decreasing incidence, mortality, and late-stage disease presentation. The fecal immunochemical test (FIT) is a screening test that aims to detect human hemoglobin in the stool. FIT is the most common CRC screening modality worldwide and second most common in the United States. Its use in screening programs has been shown to increase screening uptake and improve CRC outcomes. However, FIT-based screening programs vary widely in quality and effectiveness. In health systems with high-quality FIT screening programs, only superior FIT formats are used, providers order FIT appropriately, annual patient participation is high, and diagnostic follow-up after an abnormal result is achieved in a timely manner. Proper utilization of FIT involves multiple steps beyond provider recommendation of the test. In this commentary, we aim to highlight ongoing challenges in FIT screening and suggest interventions to maximize FIT effectiveness. Through active engagement of patients and providers, health systems can use FIT to help optimize CRC screening rates and improve CRC outcomes.
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17
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Adams MA, Rubenstein JH, Lipson R, Holleman RG, Saini SD. Trends in Wait Time for Outpatient Colonoscopy in the Veterans Health Administration, 2008-2015. J Gen Intern Med 2020; 35:1776-1782. [PMID: 32212093 PMCID: PMC7280466 DOI: 10.1007/s11606-020-05776-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Revised: 01/30/2020] [Accepted: 03/06/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND The Veterans Health Administration (VA) recently has been scrutinized for prolonged wait times for routine medical care, including elective outpatient procedures such as colonoscopy. Wait times for colonoscopy following positive fecal occult blood test (FOBT) are associated with worse clinical outcomes only if greater than 6 months. OBJECTIVE We aimed to investigate time trends in wait time for outpatient colonoscopy in VA and factors influencing wait time. DESIGN Retrospective cohort study using mixed-effects regression of VA administrative data from the Corporate Data Warehouse. PARTICIPANTS Veterans who underwent outpatient colonoscopy for positive FOBT in 2008-2015 at 124 VA endoscopy facilities. MAIN MEASURES The main outcome measure was wait time (in days) between positive FOBT and colonoscopy completion, stratified by year and adjusted for sedation type, year, and potentially influential patient- and facility-level factors. KEY RESULTS In total, 125,866 outpatient colonoscopy encounters for positive FOBT occurred during the study period. The number of colonoscopies for this indication declined slightly over time (17,586 in 2008 vs. 13,245 in 2015; range 13,425-19,814). In 2008, median wait time across sites was 50 days (interquartile range [IQR] = 33, 75). There was no secular trend in wait times (2015 median = 52 days, IQR = 34, 77). Examining the adjusted effect of patient- and facility-level factors on wait time, no clinically meaningful difference was found. CONCLUSIONS Wait times for colonoscopy for positive FOBT have been stable over time. Despite the perception of prolonged VA wait times, wait times for outpatient colonoscopy for positive FOBT are well below the threshold at which clinically meaningful differences in patient outcomes have been observed.
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Affiliation(s)
- Megan A Adams
- Center for Clinical Management Research, Department of Veterans Affairs, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA.
- Division of Gastroenterology, Department of Internal Medicine, University of Michigan Health System, Ann Arbor, MI, USA.
- Institute for Healthcare Policy and Innovation, Ann Arbor, MI, USA.
| | - Joel H Rubenstein
- Center for Clinical Management Research, Department of Veterans Affairs, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
- Division of Gastroenterology, Department of Internal Medicine, University of Michigan Health System, Ann Arbor, MI, USA
- Institute for Healthcare Policy and Innovation, Ann Arbor, MI, USA
| | - Rachel Lipson
- Center for Clinical Management Research, Department of Veterans Affairs, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Robert G Holleman
- Center for Clinical Management Research, Department of Veterans Affairs, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Sameer D Saini
- Center for Clinical Management Research, Department of Veterans Affairs, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
- Division of Gastroenterology, Department of Internal Medicine, University of Michigan Health System, Ann Arbor, MI, USA
- Institute for Healthcare Policy and Innovation, Ann Arbor, MI, USA
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18
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Paltiel O, Keidar Tirosh A, Paz Stostky O, Calderon-Margalit R, Cohen AD, Elran E, Valinsky L, Matz E, Krieger M, Yehuda AB, Jaffe DH, Manor O. Adherence to national guidelines for colorectal cancer screening in Israel: Comprehensive multi-year assessment based on electronic medical records. J Med Screen 2020; 28:25-33. [PMID: 32356670 DOI: 10.1177/0969141320919152] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVES To assess time trends in colorectal cancer screening uptake, time-to-colonoscopy completion following a positive fecal occult blood test and associated patient factors, and the extent and predictors of longitudinal screening adherence in Israel. SETTING Nation-wide population-based study using data collected from four health maintenance organizations for the Quality Indicators in Community Healthcare Program. METHODS Screening uptake for the eligible population (aged 50-74) was recorded 2003-2018 using aggregate data. For a subcohort (2008-2012, N = 1,342,617), time-to-colonoscopy following a positive fecal occult blood test and longitudinal adherence to screening guidelines were measured using individual-level data, and associated factors assessed in multivariate models. RESULTS The annual proportion screened rose for both sexes from 11 to 65%, increasing five-fold for age group 60-74 and >six-fold for 50-59 year olds, respectively. From 2008 to 2012, 67,314 adults had a positive fecal occult blood test, of whom 71% eventually performed a colonoscopy after a median interval of 122 (95% confidence interval 110.2-113.7) days. Factors associated with time-to-colonoscopy included age, socioeconomic status, and comorbidities. Only 25.5% of the population demonstrated full longitudinal screening adherence, mainly attributable to colonoscopy in the past 10 years rather than annual fecal occult blood test performance (83% versus 17%, respectively). Smoking, diabetes, lower socioeconomic status, cardiovascular disease, and hypertension were associated with decreased adherence. Performance of other cancer screening tests and frequent primary care visits were strongly associated with adherence. CONCLUSIONS Despite substantial improvement in colorectal cancer screening uptake on a population level, individual-level data uncovered gaps in colonoscopy completion after a positive fecal occult blood test and in longitudinal adherence to screening, which should be addressed using focused interventions.
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Affiliation(s)
- Ora Paltiel
- Braun School of Public Health and Community Medicine, Hadassah-Hebrew University, Jerusalem, Israel.,Quality Indicators in Community Healthcare Program, Jerusalem, Israel
| | - Aravah Keidar Tirosh
- Braun School of Public Health and Community Medicine, Hadassah-Hebrew University, Jerusalem, Israel.,Quality Indicators in Community Healthcare Program, Jerusalem, Israel
| | - Orit Paz Stostky
- Pharmacy Department, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
| | - Ronit Calderon-Margalit
- Braun School of Public Health and Community Medicine, Hadassah-Hebrew University, Jerusalem, Israel.,Quality Indicators in Community Healthcare Program, Jerusalem, Israel
| | - Arnon D Cohen
- Department of Quality Measurements and Research, Chief Physician's Office, Clalit Health Services, Tel Aviv, Israel
| | - Einat Elran
- Quality Management Department, Maccabi Healthcare Services, Tel Aviv, Israel
| | - Liora Valinsky
- Quality Department, Meuhedet Health Care, Tel Aviv, Israel
| | - Eran Matz
- Community Health Services, Leumit Health Services, Tel Aviv, Israel
| | - Michal Krieger
- Quality Indicators in Community Healthcare Program, Jerusalem, Israel
| | - Arye Ben Yehuda
- Quality Indicators in Community Healthcare Program, Jerusalem, Israel.,Department of Internal Medicine, Hadassah-Hebrew University, Jerusalem, Israel
| | - Dena H Jaffe
- Braun School of Public Health and Community Medicine, Hadassah-Hebrew University, Jerusalem, Israel.,Quality Indicators in Community Healthcare Program, Jerusalem, Israel
| | - Orly Manor
- Braun School of Public Health and Community Medicine, Hadassah-Hebrew University, Jerusalem, Israel.,Quality Indicators in Community Healthcare Program, Jerusalem, Israel
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19
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O'Connor EA, Nielson CM, Petrik AF, Green BB, Coronado GD. Prospective Cohort study of Predictors of Follow-Up Diagnostic Colonoscopy from a Pragmatic Trial of FIT Screening. Sci Rep 2020; 10:2441. [PMID: 32051454 PMCID: PMC7016148 DOI: 10.1038/s41598-020-59032-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Accepted: 01/23/2020] [Indexed: 01/18/2023] Open
Abstract
The goal of this study was to explore diagnostic colonoscopy completion in adults with abnormal screening fecal immunochemical test (FIT) results. This was a secondary analysis of the Strategies and Opportunities to Stop Colon Cancer in Priority Populations (Stop CRC) study, a cluster-randomized pragmatic trial to increase uptake of CRC screening in federally qualified community health clinics. Diagnostic colonoscopy completion and reasons for non-completion were ascertained through a manual review of electronic health records, and completion was compared across a wide range of individual patient health and sociodemographic characteristics. Among 2,018 adults with an abnormal FIT result, 1066 (52.8%) completed a follow-up colonoscopy within 12 months. Completion was generally similar across a wide range of participant subpopulations; however, completion was higher for participants who were younger, Hispanic, Spanish-speaking, and had zero or one of the Charlson medical comorbidities, compared to their counterparts. Neighborhood-level predictors were not associated with diagnostic colonoscopy completion. Thus, completion of a diagnostic colonoscopy was relatively low in a large sample of community health clinic adults who had an abnormal screening FIT result. While completion was generally similar across a wide range of characteristics, younger, healthier, Hispanic participants tended to have a higher likelihood of completion.
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Affiliation(s)
- Elizabeth A O'Connor
- Kaiser Permanente Center for Health Research, 3800 N. Interstate Avenue, Portland, OR, 97227, USA. Elizabeth.O'
| | - Carrie M Nielson
- Kaiser Permanente Center for Health Research, 3800 N. Interstate Avenue, Portland, OR, 97227, USA
| | - Amanda F Petrik
- Kaiser Permanente Center for Health Research, 3800 N. Interstate Avenue, Portland, OR, 97227, USA
| | - Beverly B Green
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Avenue, Suite 1600, Seattle, WA, 98101, USA
| | - Gloria D Coronado
- Kaiser Permanente Center for Health Research, 3800 N. Interstate Avenue, Portland, OR, 97227, USA
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20
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Kim BC, Kang M, Park E, Shim JI, Kang S, Lee J, Tchoe HJ, Kong KA, Kim DH, Kim YJ, Choi KS, Moon CM. Clinical Factors Associated with Adherence to the Follow-Up Examination after Positive Fecal Occult Blood Test in National Colorectal Cancer Screening. J Clin Med 2020; 9:E260. [PMID: 31963658 PMCID: PMC7019756 DOI: 10.3390/jcm9010260] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Revised: 01/13/2020] [Accepted: 01/15/2020] [Indexed: 12/12/2022] Open
Abstract
Background: The compliance with the follow-up examination after a positive fecal occult blood test (FOBT) is lower than expected. We aimed to evaluate the adherence rate to the follow-up examination in patients with a positive FOBT and to identify the clinical factors associated with this adherence. METHODS The study population comprised adults aged ≥50 years who participated in the National Cancer Screening Program for colorectal cancer (CRC) in 2013. Compliance was defined as undergoing follow-up examination within 1 year of a positive FOBT. RESULTS From 214,131 individuals with a positive FOBT, 120,911 (56.5%) were in the compliance group and 93,220 (43.5%) were in the non-compliance group. On multivariate analysis, good compliance was associated with men (odds ratio (OR) = 1.12, 95% confidence interval (CI) (1.09-1.15)), younger ages (70-79 years, OR = 2.19 (2.09-2.31); 60-69 years, OR = 3.29 (3.13-3.46); 50-59 years, OR = 3.57 (3.39-3.75) vs. >80 years), previous experience of CRC screening (a negative FOBT, OR = 1.18 (1.15-1.21); a positive FOBT, OR = 2.42 (2.31-2.54)), absent previous experience of colonoscopy or barium enema (OR = 2.06 (1.99-2.13)), higher economic income (quartile, 75%, OR = 1.14 (1.11-1.17); 100%, OR = 1.22 (1.19-1.25)), current smokers (OR = 1.12 (1.09-1.15)), alcohol intake (OR = 1.03 (1.01-1.05)), active physical activity (≥3 times/week, OR = 1.13 (1.11-1.15)), depression (OR = 1.11 (1.08-1.14)), and present comorbidities (Charlson Comorbidity Index, ≥1). CONCLUSION This study identified clinical factors, namely, male, younger ages, prior experience of fecal test, absent history of colonoscopy or double-contrast barium enema (DCBE) within 5 years, and high socioeconomic status to be associated with good adherence to the follow-up examination after a positive FOBT.
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Affiliation(s)
- Byung Chang Kim
- Center for Colorectal Cancer, Center for Cancer Prevention and Detection, Cancer Epidemiology Branch, Research Institute and Hospital, National Cancer Center, Goyang-si, Gyeonggi-do 10408, Korea;
| | - Minjoo Kang
- National Evidence-Based Healthcare Collaborating Agency (NECA), Seoul, Korea; (M.K.); (E.P.); (J.-I.S.); (S.K.); (J.L.); (H.J.T.)
| | - Eunjung Park
- National Evidence-Based Healthcare Collaborating Agency (NECA), Seoul, Korea; (M.K.); (E.P.); (J.-I.S.); (S.K.); (J.L.); (H.J.T.)
| | - Jeong-Im Shim
- National Evidence-Based Healthcare Collaborating Agency (NECA), Seoul, Korea; (M.K.); (E.P.); (J.-I.S.); (S.K.); (J.L.); (H.J.T.)
| | - Shinhee Kang
- National Evidence-Based Healthcare Collaborating Agency (NECA), Seoul, Korea; (M.K.); (E.P.); (J.-I.S.); (S.K.); (J.L.); (H.J.T.)
| | - Jessie Lee
- National Evidence-Based Healthcare Collaborating Agency (NECA), Seoul, Korea; (M.K.); (E.P.); (J.-I.S.); (S.K.); (J.L.); (H.J.T.)
| | - Ha Jin Tchoe
- National Evidence-Based Healthcare Collaborating Agency (NECA), Seoul, Korea; (M.K.); (E.P.); (J.-I.S.); (S.K.); (J.L.); (H.J.T.)
| | - Kyeong Ae Kong
- Department of Preventive Medicine, College of Medicine, Ewha Womans University, Seoul 03760, Korea;
| | - Duk Hwan Kim
- Digestive Disease Center, Department of Internal Medicine, CHA University School of Medicine, Gyeonggi-do 11160, Korea;
| | - Yu Jin Kim
- Department of Internal Medicine, Hallym University College of Medicine, Gangwon-do 24252, Korea;
| | - Kui Son Choi
- Department of Cancer Control and Population Health, Graduate School of Cancer Science and Policy, National Cancer Center, 323 Ilsan-ro, Ilsandong-gu, Goyang-si, Gyeonggi-do 10408, Korea
| | - Chang Mo Moon
- Department of Internal Medicine, College of Medicine, Ewha Womans University, 1071 Anyangcheon-ro, Yangcheon-gu, Seoul 07985, Korea
- Tissue Injury Defense Research Center, Ewha Womans University, Seoul 03760, Korea
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21
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Kato T, Nagata K, Yamamichi J, Tanaka S, Honda T, Shimizu N, Utano K, Hirayama M, Matsumoto H, Horita S. Preference and Experience of Colonic Examination for Participants Presenting to Hospitals with a Positive Fecal Immunochemical Test Result. Patient Prefer Adherence 2020; 14:2017-2025. [PMID: 33122895 PMCID: PMC7588835 DOI: 10.2147/ppa.s267354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 10/10/2020] [Indexed: 12/24/2022] Open
Abstract
PURPOSE Patients who test positive on the fecal immunochemical test (FIT) for colorectal cancer (CRC) are referred for colonoscopy for further diagnostic evaluation. Colonoscopy is not a perfect method and may be a challenge for some FIT-positive patients. Computed tomographic colonography (CTC) is an alternative method that is less invasive and allows examination of the whole colon. The study objective was to evaluate the preference of FIT-positive patients for either colonoscopy or CTC for CRC examination. PATIENTS AND METHODS Individuals older than 40 years with a positive FIT test at eight Japanese hospitals between December 2012 and July 2015 were invited to participate. Participants were given detailed information regarding colonoscopy and CTC before deciding on either examination. They completed questionnaires before the procedure regarding their preference and after the procedure regarding their experience. RESULTS The pre- and post-questionnaires of 846 and 834 participants, respectively, were analyzed. Participants preferred colonoscopy over CTC (colonoscopy, 72%; CTC, 28%). The possibility of obtaining biopsy samples and removing colorectal polyps during the procedure was the main reason for colonoscopy selection. Patients selected CTC to reduce discomfort but reported that CTC bowel preparation was more burdensome than colonoscopy bowel preparation. The overall experience of the examination did not differ between the groups. CONCLUSION Colonoscopy is the standard examination for FIT-positive patients. However, when given a choice, almost one-third of participants chose CTC because they thought it would be a more "comfortable" examination. Clinicians should therefore be aware of patients' potential preference for noninvasive colorectal examinations.
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Affiliation(s)
- Takashi Kato
- Department of Internal Medicine, Hokkaido Gastroenterological Hospital, Sapporo, Japan
- Correspondence: Takashi KatoDepartment of Internal Medicine, Hokkaido Gastroenterological Hospital, Sapporo, Hokkaido065-0041, JapanTel +8111-784-1811Fax +8111-784-1838 Email
| | - Koichi Nagata
- Department of Gastroenterology, Fukushima Medical University School of Medicine, Fukushima, Japan
- Cancer Screening Center, National Cancer Center Hospital, Tokyo, Japan
| | - Junta Yamamichi
- Division of Hematology, Respiratory Medicine and Oncology, Department of Internal Medicine, Faculty of Medicine, Saga University, Saga, Japan
| | - Soichi Tanaka
- Department of Coloproctology, Matsuaikai Matsuda Hospital, Hamamatsu, Japan
| | - Tetsuro Honda
- Department of Gastroenterology, Nagasaki Harbor Medical Center, Nagasaki, Japan
| | - Norihito Shimizu
- Department of Radiology, Medical Corporation Matsuoka Clinic, Nara, Japan
| | - Kenichi Utano
- Department of Coloproctology, Aizu Medical Center, Fukushima Medical University, Aizuwakamatsu, Fukushima, Japan
| | | | - Hiroshi Matsumoto
- Department of Gastroenterology, Kawasaki Medical University School of Medicine, Kurashiki, Japan
| | - Shoichi Horita
- Department of Internal Medicine, Hokkaido Gastroenterological Hospital, Sapporo, Japan
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Do socioeconomic factors play a role in nonadherence to follow-up colonoscopy after a positive faecal immunochemical test in the Flemish colorectal cancer screening programme? Eur J Cancer Prev 2019; 29:119-126. [PMID: 31724969 DOI: 10.1097/cej.0000000000000533] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVE In Flanders (Belgium), a population-based colorectal cancer (CRC) screening programme was started in 2013, coordinated by the Centre for Cancer Detection (CCD) in cooperation with the Belgian Cancer Registry (BCR). The CCD offers a biennial faecal immunochemical test (FIT) to Flemish citizens aged 56-74 years and recommends a colonoscopy when screened positive by FIT. The study objective is to investigate sociodemographic differences in follow-up colonoscopy adherence after a positive FIT. METHODS Characteristics of the study population were derived by linkage of data from the CCD and BCR, linked with data of the Intermutualistic Agency and the Crossroads Bank for Social Security, resulting in aggregated tables to ensure anonymity. A total of 37 834 men and women aged 56-74 years with a positive FIT in 2013-2014 were included. Adherence to follow-up colonoscopy was calculated for age, sex, work intensity at household level, preferential reimbursement status, and first and current nationality. Descriptive analyses and logistic regressions were performed. RESULTS Nonadherence to follow-up colonoscopy was associated with increasing age, and was significantly higher in men [odds ratio (OR), 1.08], participants with a preferential reimbursement status (OR, 1.34), very low work intensity (OR, 1.41), no payed work (OR, 1.38) and other than Belgian nationality by birth (OR, 1.6-4.66). CONCLUSION Adherence to follow-up colonoscopy after a positive FIT differs according to sociodemographic variables. Additional research is needed to explore reasons for nonadherence to colonoscopy and tackle barriers by exploring interventions to increase colonoscopy follow-up adherence after a positive FIT in the Flemish colorectal cancer screening programme.
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Heavener T, McStay FW, Jaeger V, Stephenson K, Sager L, Sing J. Assessing adherence and cost-benefit of colorectal cancer screening for accountable providers. Proc AMIA Symp 2019; 32:490-497. [PMID: 31656403 DOI: 10.1080/08998280.2019.1647702] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 07/11/2019] [Accepted: 07/18/2019] [Indexed: 01/07/2023] Open
Abstract
The objective of this study was to assess adherence and costs-benefits of colorectal cancer (CRC) screenings from an accountable care organization/population health perspective. We performed a retrospective review of 94 patients (50-75 years of age) in an integrated safety net system for whom fecal CRC screening was abnormal for the period of June 1, 2014, to June 1, 2016. A cost-benefit model was constructed using Medicare payment rates and a sensitivity analysis. Most patients included in the study (64/94, 68%) received or were offered a colonoscopy. Of those receiving a colonoscopy, 24 of 45 (53%) had an abnormal finding. Total direct medical costs avoided by screening the patient panel was $32,926 but could have exceeded $63,237 had more patients received follow-up colonoscopies. A sensitivity analysis with 1000 patients demonstrated total monetary benefits between $2.2 million and $8.16 million when follow-up and colonoscopy rates were allowed to vary. Although the resulting rates of follow-up were within the range reported in the literature, there is room for improvement, especially considering the monetary benefit that could be used on other diseases. Health systems and payers should work cooperatively to structure payment models to better incentivize CRC screenings.
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Affiliation(s)
- Trace Heavener
- Department of Internal Medicine, Baylor Scott & White Medical Center-TempleTempleTexas
| | - Frank W McStay
- Center for Healthcare Policy, Baylor Scott & White Medical Center-TempleTempleTexas
| | - Victoria Jaeger
- Department of Internal Medicine, Baylor Scott & White Medical Center-TempleTempleTexas
| | - Kristen Stephenson
- Department of Internal Medicine, Baylor Scott & White Medical Center-TempleTempleTexas
| | - Lauren Sager
- Office of Biostatistics, Baylor Scott & White Medical Center-TempleTempleTexas
| | - James Sing
- Department of Gastroenterology, Baylor Scott & White Medical Center-TempleTempleTexas
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24
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Hissong E, Pittman ME. Colorectal carcinoma screening: Established methods and emerging technology. Crit Rev Clin Lab Sci 2019; 57:22-36. [PMID: 31603697 DOI: 10.1080/10408363.2019.1670614] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
Colorectal carcinoma screening programs have shown success in lowering both the incidence and mortality rate of colorectal carcinoma at a population level, in part because this carcinoma is relatively slow growing and has an identifiable premalignant lesion. Still, many patients do not undergo the recommended screening for colorectal carcinoma, and of those who do, a subset may be over- or under-diagnosed by the currently available testing methods. The primary purpose of this article is to review the data regarding currently available colorectal cancer screening modalities, which include fecal occult blood testing, direct colonic visualization, and noninvasive imaging techniques. In addition, readers will be introduced to a variety of biomarkers that may serve as stand-alone or adjunct tests in the future. Finally, there is a brief discussion of the current epidemiologic considerations that public health officials must address as they create population screening guidelines. The data we provide as laboratory physicians and scientists are critical to the construction of appropriate recommendations that ultimately decrease the burden of disease from colorectal carcinoma.
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Affiliation(s)
- Erika Hissong
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York City, NY, USA
| | - Meredith E Pittman
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York City, NY, USA
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25
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Selby K, Jensen CD, Zhao WK, Lee JK, Slam A, Schottinger JE, Bacchetti P, Levin TR, Corley DA. Strategies to Improve Follow-up After Positive Fecal Immunochemical Tests in a Community-Based Setting: A Mixed-Methods Study. Clin Transl Gastroenterol 2019; 10:e00010. [PMID: 30829917 PMCID: PMC6407828 DOI: 10.14309/ctg.0000000000000010] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Accepted: 01/07/2019] [Indexed: 01/07/2023] Open
Abstract
OBJECTIVES The effectiveness of fecal immunochemical test (FIT) screening for colorectal cancer depends on timely colonoscopy follow-up of positive tests, although limited data exist regarding effective system-level strategies for improving follow-up rates. METHODS Using a mixed-methods design (qualitative and quantitative), we first identified system-level strategies that were implemented for improving timely follow-up after a positive FIT test in a large community-based setting between 2006 and 2016. We then evaluated changes in time to colonoscopy among FIT-positive patients across 3 periods during the study interval, controlling for screening participant age, sex, race/ethnicity, comorbidity, FIT date, and previous screening history. RESULTS Implemented strategies over the study period included setting a goal of colonoscopy follow-up within 30 days of a positive FIT, tracking FIT-positive patients, early telephone contact to directly schedule follow-up colonoscopies, assigning the responsibility for follow-up tracking and scheduling to gastroenterology departments (vs primary care), and increasing colonoscopy capacity. Among 160,051 patients who had a positive FIT between 2006 and 2016, 126,420 (79%) had a follow-up colonoscopy within 180 days, including 67% in 2006-2008, 79% in 2009-2012, and 83% in 2013-2016 (P < 0.001). Follow-up within 180 days in 2016 varied moderately across service areas, between 72% (95% CI 70-75) and 88% (95% CI 86-91), but there were no obvious differences in the pattern of strategies implemented in higher- vs lower-performing service areas. CONCLUSIONS The implementation of system-level strategies coincided with substantial improvements in timely colonoscopy follow-up after a positive FIT. Intervention studies are needed to identify the most effective strategies for promoting timely follow-up.
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Affiliation(s)
- Kevin Selby
- Kaiser Permanente Division of Research, Oakland, California, USA
- Department of Ambulatory Care and Community Medicine, University of Lausanne, Lausanne, Switzerland
| | | | - Wei K. Zhao
- Kaiser Permanente Division of Research, Oakland, California, USA
| | - Jeffrey K. Lee
- Kaiser Permanente Division of Research, Oakland, California, USA
| | | | - Joanne E. Schottinger
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Peter Bacchetti
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California, USA
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Barriers to Follow-up Colonoscopies for Patients With Positive Results From Fecal Immunochemical Tests During Colorectal Cancer Screening. Clin Gastroenterol Hepatol 2019; 17:469-476. [PMID: 29857147 DOI: 10.1016/j.cgh.2018.05.022] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Revised: 04/24/2018] [Accepted: 05/20/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Colorectal cancer is common yet largely preventable. The fecal immunochemical test (FIT) is a highly recommended screening method, but patients with positive results must receive a follow-up colonoscopy to determine if they have precancerous or cancerous lesions. We characterized colonoscopic follow-up evaluations and reasons for lack of follow-up in a Veterans Affairs (VA) cohort. METHODS We conducted a retrospective cross-sectional analysis of patients 50 to 75 years old with a positive FIT result from January 1, 2014, through May 31, 2016, in a network of 12 VAs sites in southern California. We determined the proportion of patients who received a follow-up colonoscopy, median time to colonoscopy, and colonoscopy findings. For patients who did not undergo colonoscopy, we determined the documented reason for lack of colonoscopy and factors associated with declining the colonoscopy examination. RESULTS Of the 10,635 FITs performed, 916 (8.6%) produced positive results; 569 of these (62.1%) were followed by colonoscopy. The median time to colonoscopy after a positive FIT result was 83 days (interquartile range, 54-145 d), which did not vary between veterans who received a colonoscopy at a VA facility (81 d; interquartile range, 52-143 d) vs a non-VA site (87 d; interquartile range, 60-154 d) (P = .2). For the 347 veterans (37.9%) who did not undergo follow-up colonoscopy, the reasons were patient-related (49.3%), provider-related (16.4%), system-related (12.1%), or multifactorial (22.2%). Overall, patient decline of colonoscopy (35.2%) was the most common reason. CONCLUSIONS In a cohort of veterans with positive results from FITs during CRC screening, reasons for lack of follow-up colonoscopy varied and included patient, provider, and system factors. These findings can be used to reduce barriers to follow-up colonoscopy and to address system-level challenges in scheduling and attrition for colonoscopy.
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Doubeni CA, Fedewa SA, Levin TR, Jensen CD, Saia C, Zebrowski AM, Quinn VP, Rendle KA, Zauber AG, Becerra-Culqui TA, Mehta SJ, Fletcher RH, Schottinger J, Corley DA. Modifiable Failures in the Colorectal Cancer Screening Process and Their Association With Risk of Death. Gastroenterology 2019; 156:63-74.e6. [PMID: 30268788 PMCID: PMC6309478 DOI: 10.1053/j.gastro.2018.09.040] [Citation(s) in RCA: 68] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Revised: 09/14/2018] [Accepted: 09/18/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIMS Colorectal cancer (CRC) deaths occur when patients do not receive screening or have inadequate follow-up of abnormal results or when the screening test fails. We have few data on the contribution of each to CRC-associated deaths or factors associated with these events. METHODS We performed a retrospective cohort study of patients in the Kaiser Permanente Northern and Southern California systems (55-90 years old) who died of CRC from 2006 through 2012 and had ≥5 years of enrollment before diagnosis. We compared data from patients with those from a matched cohort of cancer-free patients in the same system. Receipt, results, indications, and follow-up of CRC tests in the 10-year period before diagnosis were obtained from electronic databases and chart audits. RESULTS Of 1750 CRC deaths, 75.9% (n = 1328) occurred in patients who were not up to date in screening and 24.1% (n = 422) occurred in patients who were up to date. Failure to screen was associated with fewer visits to primary care physicians. Of 3486 cancer-free patients, 44.6% were up to date in their screening. Patients who were up to date in their screening had a lower risk of CRC death (odds ratio, 0.38; 95% confidence interval, 0.33-0.44). Failure to screen, or failure to screen at appropriate intervals, occurred in a 67.8% of patients who died of CRC vs 53.2% of cancer-free patients; failure to follow-up on abnormal results occurred in 8.1% of patients who died of CRC vs 2.2% of cancer-free patients. CRC death was associated with higher odds of failure to screen or failure to screen at appropriate intervals (odds ratio, 2.40; 95% confidence interval, 2.07-2.77) and failure to follow-up on abnormal results (odds ratio, 7.26; 95% confidence interval, 5.26-10.03). CONCLUSIONS Being up to date on screening substantially decreases the risk of CRC death. In 2 health care systems with high rates of screening, most people who died of CRC had failures in the screening process that could be rectified, such as failure to follow-up on abnormal findings; these significantly increased the risk for CRC death.
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Affiliation(s)
- Chyke A. Doubeni
- Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA,Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Stacey A. Fedewa
- Surveillance and Health Services Research, American Cancer Society, Atlanta, GA
| | - Theodore R. Levin
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | | | - Chelsea Saia
- Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Alexis M. Zebrowski
- Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA,Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Virginia P. Quinn
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - Katharine A. Rendle
- Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Ann G. Zauber
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | | | - Shivan J. Mehta
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | | | - Joanne Schottinger
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - Douglas A. Corley
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
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28
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Llovet D, Serenity M, Conn LG, Bravo CA, McCurdy BR, Dubé C, Baxter NN, Paszat L, Rabeneck L, Peters A, Tinmouth J. Reasons For Lack of Follow-up Colonoscopy Among Persons With A Positive Fecal Occult Blood Test Result: A Qualitative Study. Am J Gastroenterol 2018; 113:1872-1880. [PMID: 30361625 PMCID: PMC6768592 DOI: 10.1038/s41395-018-0381-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Accepted: 08/25/2018] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Follow-up colonoscopy rates among persons with positive fecal occult blood test results (FOBT + ) remain suboptimal in many jurisdictions. In Ontario, Canada, primary care providers (PCPs) are responsible for arranging follow-up colonoscopies. The objectives were to understand the reasons for a lack of follow-up colonoscopy and any action plans to address follow-up. METHODS Semi-structured interviews were conducted with 30 FOBT+ persons and 30 PCPs in Ontario. Eligible FOBT+ persons were identified through administrative databases and included those aged 50-74, with a 6-12 month old FOBT+, no follow-up colonoscopy, and no prior colorectal cancer diagnosis or colectomy. Eligible PCPs had ≥1 rostered FOBT+ person without follow-up colonoscopy. Transcripts were analyzed inductively using Nvivo 11 (QSR International Pty Ltd., 2015). RESULTS Reasons for lack of follow-up colonoscopy were: person and/or provider believed the FOBT + was a false positive; person was afraid of colonoscopy; person had other health issues; and breakdown in communication of FOBT+ results or colonoscopy appointments. PCPs who initially recommended follow-up colonoscopy did not change the minds of the persons who dismissed the FOBT+ as a false positive and/or who were afraid of the procedure. These FOBT+ persons negotiated an alternative follow-up action plan including repeating the FOBT or not following-up. CONCLUSIONS PCPs may not adequately counsel FOBT+ persons who believe the FOBT+ is a false positive and/or fear colonoscopy. PCPs may lack fail-safe systems to communicate FOBT+ results and colonoscopy appointments. Using navigators may help address these barriers and increase follow-up rates.
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Affiliation(s)
- Diego Llovet
- 1Cancer Care Ontario, Toronto, Canada.,2Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | | | - Lesley Gotlib Conn
- 2Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada.,3Sunnybrook Research Institute, Toronto, Canada
| | | | | | - Catherine Dubé
- 1Cancer Care Ontario, Toronto, Canada.,4Department of Medicine, University of Ottawa, Ottawa, Canada
| | - Nancy N. Baxter
- 5Dalla Lana School of Public Health, University of Toronto, Toronto, Canada.,6Department of Surgery, St. Michael's Hospital, Toronto, Canada
| | - Lawrence Paszat
- 2Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada.,7Institute for Clinical Evaluative Sciences, Toronto, Canada
| | - Linda Rabeneck
- 1Cancer Care Ontario, Toronto, Canada.,8Department of Medicine, University of Toronto, Toronto, Canada
| | | | - Jill Tinmouth
- 1Cancer Care Ontario, Toronto, Canada.,8Department of Medicine, University of Toronto, Toronto, Canada
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29
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Thomsen MK, Rasmussen M, Njor SH, Mikkelsen EM. Demographic and comorbidity predictors of adherence to diagnostic colonoscopy in the Danish Colorectal Cancer Screening Program: a nationwide cross-sectional study. Clin Epidemiol 2018; 10:1733-1742. [PMID: 30538577 PMCID: PMC6257139 DOI: 10.2147/clep.s176923] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Predictors of participation in colorectal cancer screening with a stool sample screening modality have been widely studied, but adherence to subsequent diagnostic colonoscopy after a positive screening test has received less attention. We aimed to determine predictors of adherence to diagnostic colonoscopy in the Danish Colorectal Cancer Screening Program. METHODS We conducted a cross-sectional study using data from National Health Service registries. We included 8,112 individuals invited to screening between March 3, 2014, and August 31, 2014, who had a positive immunochemical fecal occult blood test. Potential predictors were gender, age, region of residence, Charlson Comorbidity Index (CCI) score, specific diseases (cardiovascular disease, chronic pulmonary disease, diabetes, and cancer), and number of prior hospital stays. We estimated prevalence proportion differences (PPDs) for the associations between potential predictors and adherence. RESULTS Overall, adherence to diagnostic colonoscopy was 88.6%. Adherence was lower in individuals aged 75 years compared with those aged <70 years, PPD=-4.20 (95% confidence interval [CI]: -6.19; -2.20). Adherence decreased with a higher level of comorbidity: PPD=-2.30 (95% CI: -3.87; -0.74) for a CCI score of 1-2 and PPD=-9.24 (95% CI: -12.30; -6.19) for a CCI score of ≥3 compared to 0. For specific diseases, adherence was decreased in those with a diagnosis of cardiovascular disease, chronic pulmonary disease, or diabetes, but less for cancer. When comorbidity was measured as number of prior hospital stays, the adjusted PPDs were -2.41 (95% CI: -4.43;-0.39) for one to two stays and -14.50 (95% CI: -20.30; -8.74) for three or more stays compared with no in-hospital stays. CONCLUSION Major predictors of nonadherence to diagnostic colonoscopy after a positive immunochemical fecal occult blood test were older age, a CCI score of 1 or more, cardiovascular disease, chronic pulmonary disease, diabetes, and one or more in-hospital stays within the last year.
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Affiliation(s)
| | - Morten Rasmussen
- Department of Digestive Diseases K, Bispebjerg Hospital, Copenhagen, Denmark
| | - Sisse Helle Njor
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark,
- Department of Public Health Programs, Randers Regional Hospital, Randers, Denmark
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Khoong EC, Cherian R, Rivadeneira NA, Gourley G, Yazdany J, Amarnath A, Schillinger D, Sarkar U. Accurate Measurement In California's Safety-Net Health Systems Has Gaps And Barriers. Health Aff (Millwood) 2018; 37:1760-1769. [PMID: 30395496 DOI: 10.1377/hlthaff.2018.0709] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Patient safety in ambulatory care has not been routinely measured. California implemented a pay-for-performance program in safety-net hospitals that incentivized measurement and improvement in key areas of ambulatory safety: referral completion, medication safety, and test follow-up. We present two years of program data (collected during July 2015-June 2017) and show both suboptimal performance in aspects of ambulatory safety and questionable reliability in data reporting. Performance was better in areas that required limited coordination or patient engagement-for example, annual medication monitoring versus follow-up after high-risk mammograms. Health care systems that lack seamlessly integrated electronic health records and patient registries encountered barriers to reporting reliable ambulatory safety data, particularly for measures that integrated multiple data elements. These data challenges precluded accurate performance measurement in many areas. Policy makers and safety advocates need to support the development of information systems and measures that facilitate the accurate ascertainment of the health systems, patients, and clinical tasks at greatest risk for ambulatory safety failures.
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Affiliation(s)
- Elaine C Khoong
- Elaine C. Khoong ( ) is a primary care research fellow in the Division of General Internal Medicine, University of California San Francisco (UCSF), and the Zuckerberg San Francisco General Hospital and Trauma Center
| | - Roy Cherian
- Roy Cherian is a research data analyst at the Center for Vulnerable Populations, UCSF, and the Zuckerberg San Francisco General Hospital and Trauma Center
| | - Natalie A Rivadeneira
- Natalie A. Rivadeneira is a research data analyst at the Center for Vulnerable Populations, UCSF, and the Zuckerberg San Francisco General Hospital and Trauma Center
| | - Gato Gourley
- Gato Gourley is a project coordinator at the Center for Vulnerable Populations, UCSF, and the Zuckerberg San Francisco General Hospital and Trauma Center
| | - Jinoos Yazdany
- Jinoos Yazdany is an associate professor of medicine in the Division of Rheumatology, UCSF
| | - Ashrith Amarnath
- Ashrith Amarnath is a patient safety officer at the Sutter Medical Foundation and a former patient safety officer in the Office of the Medical Director, Department of Health Care Services, both in Sacramento, California
| | - Dean Schillinger
- Dean Schillinger is a professor of medicine at UCSF and chief of the Division of General Internal Medicine at Zuckerberg San Francisco General Hospital and Trauma Center
| | - Urmimala Sarkar
- Urmimala Sarkar is an associate professor of medicine in the Division of General Internal Medicine, UCSF, and a primary care physician at Zuckerberg San Francisco General Hospital's Richard H. Fine People's Clinic
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Wolf AMD, Fontham ETH, Church TR, Flowers CR, Guerra CE, LaMonte SJ, Etzioni R, McKenna MT, Oeffinger KC, Shih YCT, Walter LC, Andrews KS, Brawley OW, Brooks D, Fedewa SA, Manassaram-Baptiste D, Siegel RL, Wender RC, Smith RA. Colorectal cancer screening for average-risk adults: 2018 guideline update from the American Cancer Society. CA Cancer J Clin 2018; 68:250-281. [PMID: 29846947 DOI: 10.3322/caac.21457] [Citation(s) in RCA: 1141] [Impact Index Per Article: 190.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Accepted: 04/23/2018] [Indexed: 12/11/2022] Open
Abstract
In the United States, colorectal cancer (CRC) is the fourth most common cancer diagnosed among adults and the second leading cause of death from cancer. For this guideline update, the American Cancer Society (ACS) used an existing systematic evidence review of the CRC screening literature and microsimulation modeling analyses, including a new evaluation of the age to begin screening by race and sex and additional modeling that incorporates changes in US CRC incidence. Screening with any one of multiple options is associated with a significant reduction in CRC incidence through the detection and removal of adenomatous polyps and other precancerous lesions and with a reduction in mortality through incidence reduction and early detection of CRC. Results from modeling analyses identified efficient and model-recommendable strategies that started screening at age 45 years. The ACS Guideline Development Group applied the Grades of Recommendations, Assessment, Development, and Evaluation (GRADE) criteria in developing and rating the recommendations. The ACS recommends that adults aged 45 years and older with an average risk of CRC undergo regular screening with either a high-sensitivity stool-based test or a structural (visual) examination, depending on patient preference and test availability. As a part of the screening process, all positive results on noncolonoscopy screening tests should be followed up with timely colonoscopy. The recommendation to begin screening at age 45 years is a qualified recommendation. The recommendation for regular screening in adults aged 50 years and older is a strong recommendation. The ACS recommends (qualified recommendations) that: 1) average-risk adults in good health with a life expectancy of more than 10 years continue CRC screening through the age of 75 years; 2) clinicians individualize CRC screening decisions for individuals aged 76 through 85 years based on patient preferences, life expectancy, health status, and prior screening history; and 3) clinicians discourage individuals older than 85 years from continuing CRC screening. The options for CRC screening are: fecal immunochemical test annually; high-sensitivity, guaiac-based fecal occult blood test annually; multitarget stool DNA test every 3 years; colonoscopy every 10 years; computed tomography colonography every 5 years; and flexible sigmoidoscopy every 5 years. CA Cancer J Clin 2018;68:250-281. © 2018 American Cancer Society.
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Affiliation(s)
- Andrew M D Wolf
- Associate Professor and Attending Physician, University of Virginia School of Medicine, Charlottesville, VA
| | - Elizabeth T H Fontham
- Emeritus Professor, Louisiana State University School of Public Health, New Orleans, LA
| | - Timothy R Church
- Professor, University of Minnesota and Masonic Cancer Center, Minneapolis, MN
| | - Christopher R Flowers
- Professor and Attending Physician, Emory University School of Medicine and Winship Cancer Institute, Atlanta, GA
| | - Carmen E Guerra
- Associate Professor of Medicine of the Perelman School of Medicine and Attending Physician, University of Pennsylvania Medical Center, Philadelphia, PA
| | - Samuel J LaMonte
- Independent retired physician and patient advocate, University of Washington and the Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Ruth Etzioni
- Biostatistician, University of Washington and the Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Matthew T McKenna
- Professor and Director, Division of Preventive Medicine, Department of Family and Preventive Medicine, Emory University School of Medicine, Atlanta, GA
| | - Kevin C Oeffinger
- Professor and Director of the Duke Center for Onco-Primary Care, Durham, NC
| | - Ya-Chen Tina Shih
- Professor, Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Louise C Walter
- Professor and Attending Physician, University of California, San Francisco and San Francisco VA Medical Center, San Francisco, CA
| | - Kimberly S Andrews
- Director, Cancer Control Department, American Cancer Society, Atlanta, GA
| | - Otis W Brawley
- Chief Medical and Scientific Officer and Executive Vice President-Research, American Cancer Society, Atlanta, GA
| | - Durado Brooks
- Vice President, Cancer Control Interventions, Cancer Control Department, American Cancer Society, Atlanta, GA
| | - Stacey A Fedewa
- Strategic Director for Risk Factor Screening and Surveillance, American Cancer Society, Atlanta, GA
| | | | - Rebecca L Siegel
- Strategic Director, Surveillance Information Services, American Cancer Society, Atlanta, GA
| | - Richard C Wender
- Chief Cancer Control Officer, American Cancer Society, Atlanta, GA
| | - Robert A Smith
- Vice President, Cancer Screening, Cancer Control Department, American Cancer Society, Atlanta, GA
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Zorzi M, Hassan C, Selby K, Rugge M. Do not leave FIT positives alone! Am J Gastroenterol 2018; 113:913. [PMID: 29476084 DOI: 10.1038/s41395-018-0019-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Accepted: 01/03/2018] [Indexed: 12/11/2022]
Affiliation(s)
- Manuel Zorzi
- Veneto Tumour Registry, Veneto Region, Passaggio Gaudenzio, 1 - 35131, Padua, Italy. Endoscopy Unit, Nuovo Regina Margherita Hospital. Via Emilio Morosini, 30 - 00153, Rome, Italy. Kaiser Permanente Division of Research, 2000 Broadway, Oakland, CA, 94612, USA. Department of Medicine DIMED Pathology and Cytopathology Unit, University of Padua, Via Gabelli, 61 - 35121, Padua, Italy
| | - Cesare Hassan
- Veneto Tumour Registry, Veneto Region, Passaggio Gaudenzio, 1 - 35131, Padua, Italy. Endoscopy Unit, Nuovo Regina Margherita Hospital. Via Emilio Morosini, 30 - 00153, Rome, Italy. Kaiser Permanente Division of Research, 2000 Broadway, Oakland, CA, 94612, USA. Department of Medicine DIMED Pathology and Cytopathology Unit, University of Padua, Via Gabelli, 61 - 35121, Padua, Italy
| | - Kevin Selby
- Veneto Tumour Registry, Veneto Region, Passaggio Gaudenzio, 1 - 35131, Padua, Italy. Endoscopy Unit, Nuovo Regina Margherita Hospital. Via Emilio Morosini, 30 - 00153, Rome, Italy. Kaiser Permanente Division of Research, 2000 Broadway, Oakland, CA, 94612, USA. Department of Medicine DIMED Pathology and Cytopathology Unit, University of Padua, Via Gabelli, 61 - 35121, Padua, Italy
| | - Massimo Rugge
- Veneto Tumour Registry, Veneto Region, Passaggio Gaudenzio, 1 - 35131, Padua, Italy. Endoscopy Unit, Nuovo Regina Margherita Hospital. Via Emilio Morosini, 30 - 00153, Rome, Italy. Kaiser Permanente Division of Research, 2000 Broadway, Oakland, CA, 94612, USA. Department of Medicine DIMED Pathology and Cytopathology Unit, University of Padua, Via Gabelli, 61 - 35121, Padua, Italy.,Veneto Tumour Registry, Veneto Region, Passaggio Gaudenzio, 1 - 35131, Padua, Italy. Endoscopy Unit, Nuovo Regina Margherita Hospital. Via Emilio Morosini, 30 - 00153, Rome, Italy. Kaiser Permanente Division of Research, 2000 Broadway, Oakland, CA, 94612, USA. Department of Medicine DIMED Pathology and Cytopathology Unit, University of Padua, Via Gabelli, 61 - 35121, Padua, Italy
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Suhool A, Moszkowicz D, Cudennec T, Vychnevskaia K, Malafosse R, Beauchet A, Julié C, Peschaud F. Optimal oncologic treatment of rectal cancer in patients over 75 years old: Results of a strategy based on oncogeriatric evaluation. J Visc Surg 2018; 155:17-25. [PMID: 29503170 DOI: 10.1016/j.jviscsurg.2017.06.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Few data are available on the management of elderly rectal cancer patients, and especially on the ability to provide optimal oncological treatment. The aim of this study was to determine the feasibility and results of multimodality treatment for rectal cancer in patients 75years and older after simplified comprehensive geriatric assessment (CGA) according to Balducci score. METHODS We reviewed the charts of elderly patients who underwent surgery for localized middle or low rectal cancer. Patients were classified into three CGA groups depending on their functional reserve, comorbidities, geriatric syndromes, and life expectancy. RESULTS Neoadjuvant therapy was discussed for 27 patients (47%), but only 56% of them were treated, including 8, 7, and 1 patient from CGA groups 1, 2, and 3, respectively. Fifty-three patients (93%) underwent sphincter-preserving surgical resection and four patients underwent abdominoperineal resection (7%). Postoperative complications were observed in 21 patients (37%). The postoperative complication rate was correlated non-significantly with age (<85years: 40.6%; ≥85years: 57.1%; P=0.3), and with the CGA (P=0.64). In total, 10 patients (18%) had definitive colostomy, including five anastomotic leakages (9%), and one incontinence (2%). The total rate of sphincter preservation was 82% (n=47). The risk of secondary definitive colonic stoma formation was not correlated with CGA (group 1: 14%; group 2/3: 16%; P=0.8). Estimated OS at five years was 52%. CONCLUSIONS After routine geriatric assessment, elderly rectal cancer patients have good rates of sphincter conservation and acceptable morbidity/mortality.
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Affiliation(s)
- A Suhool
- Service de chirurgie digestive, oncologique et metabolique, hôpital Ambroise-Paré, AP-HP, 92100 Boulogne-Billancourt, France
| | - D Moszkowicz
- Service de chirurgie digestive, oncologique et metabolique, hôpital Ambroise-Paré, AP-HP, 92100 Boulogne-Billancourt, France; UVSQ, université Paris-Saclay, UFR des sciences de la santé Simone Veil, 78180 Montigny-Le-Bretonneux, France
| | - T Cudennec
- Service de gériatrie, hôpital Ambroise-Paré, AP-HP, 92100 Boulogne-Billancourt, France
| | - K Vychnevskaia
- Service de chirurgie digestive, oncologique et metabolique, hôpital Ambroise-Paré, AP-HP, 92100 Boulogne-Billancourt, France; UVSQ, université Paris-Saclay, UFR des sciences de la santé Simone Veil, 78180 Montigny-Le-Bretonneux, France
| | - R Malafosse
- Service de chirurgie digestive, oncologique et metabolique, hôpital Ambroise-Paré, AP-HP, 92100 Boulogne-Billancourt, France
| | - A Beauchet
- Service de biostatistiques, hôpital Ambroise-Paré, AP-HP, 92100 Boulogne-Billancourt, France
| | - C Julié
- UVSQ, université Paris-Saclay, UFR des sciences de la santé Simone Veil, 78180 Montigny-Le-Bretonneux, France; Service d'anatomo-pathologie, hôpital Ambroise-Paré, AP-HP, 92100 Boulogne-Billancourt, France
| | - F Peschaud
- Service de chirurgie digestive, oncologique et metabolique, hôpital Ambroise-Paré, AP-HP, 92100 Boulogne-Billancourt, France; UVSQ, université Paris-Saclay, UFR des sciences de la santé Simone Veil, 78180 Montigny-Le-Bretonneux, France.
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Oluloro A, Petrik AF, Turner A, Kapka T, Rivelli J, Carney PA, Saha S, Coronado GD. Timeliness of Colonoscopy After Abnormal Fecal Test Results in a Safety Net Practice. J Community Health 2018; 41:864-70. [PMID: 26874943 DOI: 10.1007/s10900-016-0165-y] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Fecal testing can only reduce colorectal cancer mortality if patients with an abnormal test result receive a follow-up colonoscopy. As part of the Strategies and Opportunities to STOP Colon Cancer in Priority Populations (STOP CRC) project, we examined factors associated with adherence to follow-up colonoscopy among patients with abnormal fecal test results. As part of STOP CRC outreach, Virginia Garcia Memorial Health Center staff distributed 1753 fecal immunochemical tests (FIT), of which 677 (39 %) were completed, and 56 had an abnormal result (8 %). Project staff used logistic regression analyses to examine factors associated with colonoscopy referral and completion. Of the 56 patients with abnormal FIT results; 45 (80 %) had evidence of a referral for colonoscopy, 32 (57 %) had evidence of a completed colonoscopy within 18 months, and 14 (25 %) within 60 days of an abnormal fecal test result. In adjusted analysis, Hispanics had lower odds of completing follow-up colonoscopy within 60 days than non-Hispanic whites (adjusted OR 0.20; 95 % CI 0.04, 0.92). Colonoscopy within 60 days trended lower for women than for men (adjusted OR 0.25; 95 % CI 0.06-1.04). Among the 24 patients lacking medical record evidence of a colonoscopy, 19 (79 %) had a documented reason, including clinician did not pursue, patient refused, and colonoscopy not indicated. No reason was found for 21 %. Improvements are needed to increase rates of follow-up colonoscopy completion, especially among female and Hispanic patients.
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Affiliation(s)
- Ann Oluloro
- Kaiser Permanente Northwest, Center for Health Research, 3800 N. Interstate Ave., Portland, OR, 97227, USA. .,Oregon Health & Sciences University, 3181 SW Sam Jackson Park Rd., Portland, OR, 97239, USA.
| | - Amanda F Petrik
- Kaiser Permanente Northwest, Center for Health Research, 3800 N. Interstate Ave., Portland, OR, 97227, USA
| | - Ann Turner
- Virginia Garcia Memorial Health Center, 226 SE 8th Ave, Hillsboro, OR, 97123, USA
| | - Tanya Kapka
- Kaiser Permanente Northwest, Center for Health Research, 3800 N. Interstate Ave., Portland, OR, 97227, USA.,Virginia Garcia Memorial Health Center, 226 SE 8th Ave, Hillsboro, OR, 97123, USA
| | - Jennifer Rivelli
- Kaiser Permanente Northwest, Center for Health Research, 3800 N. Interstate Ave., Portland, OR, 97227, USA
| | - Patricia A Carney
- Oregon Health & Sciences University, 3181 SW Sam Jackson Park Rd., Portland, OR, 97239, USA
| | - Somnath Saha
- Oregon Health & Sciences University, 3181 SW Sam Jackson Park Rd., Portland, OR, 97239, USA.,Section of General Internal Medicine, Portland VA Medical Center, 3710 SW U.S. Veterans Hospital Rd. (P3HSRD), Portland, OR, 97239, USA
| | - Gloria D Coronado
- Kaiser Permanente Northwest, Center for Health Research, 3800 N. Interstate Ave., Portland, OR, 97227, USA
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35
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Selby K, Baumgartner C, Levin TR, Doubeni CA, Zauber AG, Schottinger J, Jensen CD, Lee JK, Corley DA. Interventions to Improve Follow-up of Positive Results on Fecal Blood Tests: A Systematic Review. Ann Intern Med 2017; 167:565-575. [PMID: 29049756 PMCID: PMC6178946 DOI: 10.7326/m17-1361] [Citation(s) in RCA: 86] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Fecal immunochemical testing is the most commonly used method for colorectal cancer screening worldwide. However, its effectiveness is frequently undermined by failure to obtain follow-up colonoscopy after positive test results. PURPOSE To evaluate interventions to improve rates of follow-up colonoscopy for adults after a positive result on a fecal test (guaiac or immunochemical). DATA SOURCES English-language studies from the Cochrane Central Register of Controlled Trials, PubMed, and Embase from database inception through June 2017. STUDY SELECTION Randomized and nonrandomized studies reporting an intervention for colonoscopy follow-up of asymptomatic adults with positive fecal test results. DATA EXTRACTION Two reviewers independently extracted data and ranked study quality; 2 rated overall strength of evidence for each category of study type. DATA SYNTHESIS Twenty-three studies were eligible for analysis, including 7 randomized and 16 nonrandomized studies. Three were at low risk of bias. Eleven studies described patient-level interventions (changes to invitation, provision of results or follow-up appointments, and patient navigators), 5 provider-level interventions (reminders or performance data), and 7 system-level interventions (automated referral, precolonoscopy telephone calls, patient registries, and quality improvement efforts). Moderate evidence supported patient navigators and provider reminders or performance data. Evidence for system-level interventions was low. Seventeen studies reported the proportion of test-positive patients who completed colonoscopy compared with a control population, with absolute differences of -7.4 percentage points (95% CI, -19 to 4.3 percentage points) to 25 percentage points (CI, 14 to 35 percentage points). LIMITATION More than half of studies were at high or very high risk of bias; heterogeneous study designs and characteristics precluded meta-analysis. CONCLUSION Patient navigators and giving providers reminders or performance data may help improve colonoscopy rates of asymptomatic adults with positive fecal blood test results. Current evidence about useful system-level interventions is scant and insufficient. PRIMARY FUNDING SOURCE National Cancer Institute. (PROSPERO: CRD42016048286).
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Affiliation(s)
- Kevin Selby
- From Kaiser Permanente Division of Research, Oakland, California; University of Lausanne, Lausanne, Switzerland; University of California at San Francisco, San Francisco, California; Bern University Hospital, Bern, Switzerland; Kaiser Permanente Medical Center, Walnut Creek, California; University of Pennsylvania, Philadelphia, Pennsylvania; Memorial Sloan Kettering Cancer Center, New York, New York; and Kaiser Permanente, Pasadena, California
| | - Christine Baumgartner
- From Kaiser Permanente Division of Research, Oakland, California; University of Lausanne, Lausanne, Switzerland; University of California at San Francisco, San Francisco, California; Bern University Hospital, Bern, Switzerland; Kaiser Permanente Medical Center, Walnut Creek, California; University of Pennsylvania, Philadelphia, Pennsylvania; Memorial Sloan Kettering Cancer Center, New York, New York; and Kaiser Permanente, Pasadena, California
| | - Theodore R Levin
- From Kaiser Permanente Division of Research, Oakland, California; University of Lausanne, Lausanne, Switzerland; University of California at San Francisco, San Francisco, California; Bern University Hospital, Bern, Switzerland; Kaiser Permanente Medical Center, Walnut Creek, California; University of Pennsylvania, Philadelphia, Pennsylvania; Memorial Sloan Kettering Cancer Center, New York, New York; and Kaiser Permanente, Pasadena, California
| | - Chyke A Doubeni
- From Kaiser Permanente Division of Research, Oakland, California; University of Lausanne, Lausanne, Switzerland; University of California at San Francisco, San Francisco, California; Bern University Hospital, Bern, Switzerland; Kaiser Permanente Medical Center, Walnut Creek, California; University of Pennsylvania, Philadelphia, Pennsylvania; Memorial Sloan Kettering Cancer Center, New York, New York; and Kaiser Permanente, Pasadena, California
| | - Ann G Zauber
- From Kaiser Permanente Division of Research, Oakland, California; University of Lausanne, Lausanne, Switzerland; University of California at San Francisco, San Francisco, California; Bern University Hospital, Bern, Switzerland; Kaiser Permanente Medical Center, Walnut Creek, California; University of Pennsylvania, Philadelphia, Pennsylvania; Memorial Sloan Kettering Cancer Center, New York, New York; and Kaiser Permanente, Pasadena, California
| | - Joanne Schottinger
- From Kaiser Permanente Division of Research, Oakland, California; University of Lausanne, Lausanne, Switzerland; University of California at San Francisco, San Francisco, California; Bern University Hospital, Bern, Switzerland; Kaiser Permanente Medical Center, Walnut Creek, California; University of Pennsylvania, Philadelphia, Pennsylvania; Memorial Sloan Kettering Cancer Center, New York, New York; and Kaiser Permanente, Pasadena, California
| | - Christopher D Jensen
- From Kaiser Permanente Division of Research, Oakland, California; University of Lausanne, Lausanne, Switzerland; University of California at San Francisco, San Francisco, California; Bern University Hospital, Bern, Switzerland; Kaiser Permanente Medical Center, Walnut Creek, California; University of Pennsylvania, Philadelphia, Pennsylvania; Memorial Sloan Kettering Cancer Center, New York, New York; and Kaiser Permanente, Pasadena, California
| | - Jeffrey K Lee
- From Kaiser Permanente Division of Research, Oakland, California; University of Lausanne, Lausanne, Switzerland; University of California at San Francisco, San Francisco, California; Bern University Hospital, Bern, Switzerland; Kaiser Permanente Medical Center, Walnut Creek, California; University of Pennsylvania, Philadelphia, Pennsylvania; Memorial Sloan Kettering Cancer Center, New York, New York; and Kaiser Permanente, Pasadena, California
| | - Douglas A Corley
- From Kaiser Permanente Division of Research, Oakland, California; University of Lausanne, Lausanne, Switzerland; University of California at San Francisco, San Francisco, California; Bern University Hospital, Bern, Switzerland; Kaiser Permanente Medical Center, Walnut Creek, California; University of Pennsylvania, Philadelphia, Pennsylvania; Memorial Sloan Kettering Cancer Center, New York, New York; and Kaiser Permanente, Pasadena, California
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36
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Partin MR, Gravely AA, Burgess JF, Haggstrom DA, Lillie SE, Nelson DB, Nugent SM, Shaukat A, Sultan S, Walter LC, Burgess DJ. Contribution of patient, physician, and environmental factors to demographic and health variation in colonoscopy follow-up for abnormal colorectal cancer screening test results. Cancer 2017; 123:3502-3512. [PMID: 28493543 DOI: 10.1002/cncr.30765] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Revised: 04/10/2017] [Accepted: 04/12/2017] [Indexed: 11/09/2022]
Abstract
BACKGROUND Patient, physician, and environmental factors were identified, and the authors examined the contribution of these factors to demographic and health variation in colonoscopy follow-up after a positive fecal occult blood test/fecal immunochemical test (FOBT/FIT) screening. METHODS In total, 76,243 FOBT/FIT-positive patients were identified from 120 Veterans Health Administration (VHA) facilities between August 16, 2009 and March 20, 2011 and were followed for 6 months. Patient demographic (race/ethnicity, sex, age, marital status) and health characteristics (comorbidities), physician characteristics (training level, whether primary care provider) and behaviors (inappropriate FOBT/FIT screening), and environmental factors (geographic access, facility type) were identified from VHA administrative records. Patient behaviors (refusal, private sector colonoscopy use) were estimated with statistical text mining conducted on clinic notes, and follow-up predictors and adjusted rates were estimated using hierarchical logistic regression. RESULTS Roughly 50% of individuals completed a colonoscopy at a VHA facility within 6 months. Age and comorbidity score were negatively associated with follow-up. Blacks were more likely to receive follow-up than whites. Environmental factors attenuated but did not fully account for these differences. Patient behaviors (refusal, private sector colonoscopy use) and physician behaviors (inappropriate screening) fully accounted for the small reverse race disparity and attenuated variation by age and comorbidity score. Patient behaviors (refusal and private sector colonoscopy use) contributed more to variation in follow-up rates than physician behaviors (inappropriate screening). CONCLUSIONS In the VHA, blacks are more likely to receive colonoscopy follow-up for positive FOBT/FIT results than whites, and follow-up rates markedly decline with advancing age and comorbidity burden. Patient and physician behaviors explain race variation in follow-up rates and contribute to variation by age and comorbidity burden. Cancer 2017;123:3502-12. Published 2017. This article is a US Government work and is in the public domain in the USA.
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Affiliation(s)
- Melissa R Partin
- Center for Chronic Disease Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota.,Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Amy A Gravely
- Center for Chronic Disease Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota
| | - James F Burgess
- Center for Healthcare Organization and Implementation Research, Boston Veterans Affairs Healthcare System, Boston, Massachusetts.,Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, Massachusetts
| | - David A Haggstrom
- Veterans Affairs Health Services Research & Development Center for Health Information and Communication, Roudebush Veterans Affairs Medical Center, Indianapolis, Indiana.,Division of General Internal Medicine and Geriatrics, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Sarah E Lillie
- Center for Chronic Disease Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota.,Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - David B Nelson
- Center for Chronic Disease Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota.,Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Sean M Nugent
- Center for Chronic Disease Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota
| | - Aasma Shaukat
- Center for Chronic Disease Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota.,Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Shahnaz Sultan
- Center for Chronic Disease Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota.,Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Louise C Walter
- Division of Geriatrics, San Francisco Veterans Affairs Medical Center and University of California, San Francisco, California
| | - Diana J Burgess
- Center for Chronic Disease Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota.,Department of Medicine, University of Minnesota, Minneapolis, Minnesota
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Corley DA, Jensen CD, Quinn VP, Doubeni CA, Zauber AG, Lee JK, Schottinger JE, Marks AR, Zhao WK, Ghai NR, Lee AT, Contreras R, Quesenberry CP, Fireman BH, Levin TR. Association Between Time to Colonoscopy After a Positive Fecal Test Result and Risk of Colorectal Cancer and Cancer Stage at Diagnosis. JAMA 2017; 317:1631-1641. [PMID: 28444278 PMCID: PMC6343838 DOI: 10.1001/jama.2017.3634] [Citation(s) in RCA: 189] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
IMPORTANCE The fecal immunochemical test (FIT) is commonly used for colorectal cancer screening and positive test results require follow-up colonoscopy. However, follow-up intervals vary, which may result in neoplastic progression. OBJECTIVE To evaluate time to colonoscopy after a positive FIT result and its association with risk of colorectal cancer and advanced-stage disease at diagnosis. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study (January 1, 2010-December 31, 2014) within Kaiser Permanente Northern and Southern California. Participants were 70 124 patients aged 50 through 70 years eligible for colorectal cancer screening with a positive FIT result who had a follow-up colonoscopy. EXPOSURES Time (days) to colonoscopy after a positive FIT result. MAIN OUTCOMES AND MEASURES Risk of any colorectal cancer and advanced-stage disease (defined as stage III and IV cancer). Odds ratios (ORs) and 95% CIs were adjusted for patient demographics and baseline risk factors. RESULTS Of the 70 124 patients with positive FIT results (median age, 61 years [IQR, 55-67 years]; men, 52.7%), there were 2191 cases of any colorectal cancer and 601 cases of advanced-stage disease diagnosed. Compared with colonoscopy follow-up within 8 to 30 days (n = 27 176), there were no significant differences between follow-up at 2 months (n = 24 644), 3 months (n = 8666), 4 to 6 months (n = 5251), or 7 to 9 months (n = 1335) for risk of any colorectal cancer (cases per 1000 patients: 8-30 days, 30; 2 months, 28; 3 months, 31; 4-6 months, 31; and 7-9 months, 43) or advanced-stage disease (cases per 1000 patients: 8-30 days, 8; 2 months, 7; 3 months, 7; 4-6 months, 9; and 7-9 months, 13). Risks were significantly higher for examinations at 10 to 12 months (n = 748) for any colorectal cancer (OR, 1.48 [95% CI, 1.05-2.08]; 49 cases per 1000 patients) and advanced-stage disease (OR, 1.97 [95% CI, 1.14-3.42]; 19 cases per 1000 patients) and more than 12 months (n = 747) for any colorectal cancer (OR, 2.25 [95% CI, 1.89-2.68]; 76 cases per 1000 patients) and advanced-stage disease (OR, 3.22 [95% CI, 2.44-4.25]; 31 cases per 1000 patients). CONCLUSIONS AND RELEVANCE Among patients with a positive fecal immunochemical test result, compared with follow-up colonoscopy at 8 to 30 days, follow-up after 10 months was associated with a higher risk of colorectal cancer and more advanced-stage disease at the time of diagnosis. Further research is needed to assess whether this relationship is causal.
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Affiliation(s)
- Douglas A. Corley
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | | | - Virginia P. Quinn
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - Chyke A. Doubeni
- Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Ann G. Zauber
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Jeffrey K. Lee
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Joanne E. Schottinger
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - Amy R. Marks
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Wei K. Zhao
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Nirupa R. Ghai
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - Alexander T. Lee
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - Richard Contreras
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | | | - Bruce H. Fireman
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Theodore R. Levin
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
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Colorectal cancer screening: Systematic review of screen-related morbidity and mortality. Cancer Treat Rev 2017; 54:87-98. [DOI: 10.1016/j.ctrv.2017.02.002] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Revised: 02/02/2017] [Accepted: 02/03/2017] [Indexed: 12/12/2022]
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Plumb AA, Ghanouni A, Rainbow S, Djedovic N, Marshall S, Stein J, Taylor SA, Halligan S, Lyratzopoulos G, von Wagner C. Patient factors associated with non-attendance at colonoscopy after a positive screening faecal occult blood test. J Med Screen 2017; 24:12-19. [PMID: 27216771 DOI: 10.1177/0969141316645629] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2024]
Abstract
Background Screening participants with abnormal faecal occult blood test results who do not attend further testing are at high risk of colorectal cancer, yet little is known about their reasons for non-attendance. Methods We conducted a medical record review of 170 patients from two English Bowel Cancer Screening Programme centres who had abnormal guaiac faecal occult blood test screening tests between November 2011 and April 2013 but did not undergo colonoscopy. Using information from patient records, we coded and categorized reasons for non-attendance. Results Of the 170 patients, 82 were eligible for review, of whom 66 had at least one recorded reason for lack of colonoscopy follow-up. Reasons fell into seven main categories: (i) other commitments, (ii) unwillingness to have the test, (iii) a feeling that the faecal occult blood test result was a false positive, (iv) another health issue taking priority, (v) failing to complete bowel preparation, (vi) practical barriers (e.g. lack of transport), and (vii) having had or planning colonoscopy elsewhere. The most common single reasons were unwillingness to have a colonoscopy and being away. Conclusions We identify a range of apparent reasons for colonoscopy non-attendance after a positive faecal occult blood test screening. Education regarding the interpretation of guaiac faecal occult blood test findings, offer of alternative confirmatory test options, and flexibility in the timing or location of subsequent testing might decrease non-attendance of diagnostic testing following positive faecal occult blood test.
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Affiliation(s)
- Andrew A Plumb
- 1 Centre for Medical Imaging, University College London, London, UK
| | - Alex Ghanouni
- 2 Health Behaviour Research Centre, University College London, London, UK
| | - Sandra Rainbow
- 3 London Hub, Bowel Cancer Screening Programme, Northwick Park Hospital, Harrow, UK
| | - Natasha Djedovic
- 3 London Hub, Bowel Cancer Screening Programme, Northwick Park Hospital, Harrow, UK
| | - Sarah Marshall
- 4 St Marks Screening Centre, St Marks Hospital, Harrow, UK
| | - Judith Stein
- 5 University College Screening Centre, University College London Hospitals, London, UK
| | - Stuart A Taylor
- 1 Centre for Medical Imaging, University College London, London, UK
| | - Steve Halligan
- 1 Centre for Medical Imaging, University College London, London, UK
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Smith RA, Andrews KS, Brooks D, Fedewa SA, Manassaram-Baptiste D, Saslow D, Brawley OW, Wender RC. Cancer screening in the United States, 2017: A review of current American Cancer Society guidelines and current issues in cancer screening. CA Cancer J Clin 2017; 67:100-121. [PMID: 28170086 DOI: 10.3322/caac.21392] [Citation(s) in RCA: 274] [Impact Index Per Article: 39.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Answer questions and earn CME/CNE Each year, the American Cancer Society publishes a summary of its guidelines for early cancer detection, data and trends in cancer screening rates, and select issues related to cancer screening. In this issue of the journal, the authors summarize current American Cancer Society cancer screening guidelines, describe an update of their guideline for using human papillomavirus vaccination for cancer prevention, describe updates in US Preventive Services Task Force recommendations for breast and colorectal cancer screening, discuss interim findings from the UK Collaborative Trial on Ovarian Cancer Screening, and provide the latest data on utilization of cancer screening from the National Health Interview Survey. CA Cancer J Clin 2017;67:100-121. © 2017 American Cancer Society.
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Affiliation(s)
- Robert A Smith
- Vice President, Cancer Screening, Cancer Control Department, American Cancer Society, Atlanta, GA
| | - Kimberly S Andrews
- Director, Cancer Control Department, American Cancer Society, Atlanta, GA
| | - Durado Brooks
- Managing Director, Cancer Control Intervention, Cancer Control Department, American Cancer Society, Atlanta, GA
| | - Stacey A Fedewa
- Director for Risk Factor Screening and Surveillance, Department of Epidemiology and Research Surveillance, American Cancer Society, Atlanta, GA
| | | | - Debbie Saslow
- Senior Director, HPV Related and Women's Cancer, Cancer Control Department, American Cancer Society, Atlanta, GA
| | - Otis W Brawley
- Chief Medical Officer, American Cancer Society, Atlanta, GA
| | - Richard C Wender
- Chief Cancer Control Officer, American Cancer Society, Atlanta, GA
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Issaka RB, Singh MH, Oshima SM, Laleau VJ, Rachocki CD, Chen EH, Day LW, Sarkar U, Somsouk M. Inadequate Utilization of Diagnostic Colonoscopy Following Abnormal FIT Results in an Integrated Safety-Net System. Am J Gastroenterol 2017; 112:375-382. [PMID: 28154400 PMCID: PMC6597438 DOI: 10.1038/ajg.2016.555] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2016] [Accepted: 11/01/2016] [Indexed: 12/11/2022]
Abstract
OBJECTIVES The effectiveness of stool-based colorectal cancer (CRC) screening is contingent on colonoscopy completion in patients with an abnormal fecal immunochemical test (FIT). Understanding system and patient factors affecting follow-up of abnormal screening tests is essential to optimize care for high-risk cohorts. METHODS This retrospective cohort study was conducted in an integrated safety-net system comprised of 11 primary-care clinics and one Gastroenterology referral unit and included patients 50-75 years, with a positive FIT between April 2012 and February 2015. RESULTS Of the 2,238 patients identified, 1,245 (55.6%) completed their colonoscopy within 1-year of the positive FIT. The median time from positive FIT to colonoscopy was 184 days (interquartile range 140-232). Of the 13% of FIT positive patients not referred to gastroenterology, 49% lacked documentation addressing their abnormal result or counseling on the increased risk of CRC. Of the patients referred but who missed their appointments, 62% lacked documentation following up on the abnormal result in the absence of a completed colonoscopy. FIT positive patients never referred to gastroenterology or who missed their appointment after referrals were more likely to have comorbid conditions and documented illicit substance use compared with patients who completed a colonoscopy. CONCLUSIONS Despite access to colonoscopy and a shared electronic health record system, colonoscopy completion after an abnormal FIT is inadequate within this safety-net system. Inadequate follow-up is in part explained by inappropriate screening, but there is an absence of clear documentation and systematic workflow within both primary care and GI specialty care addressing abnormal FIT results.
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Affiliation(s)
- Rachel B. Issaka
- Division of Gastroenterology, University of California, San Francisco, San Francisco, California USA
| | - Maneesh H. Singh
- Division of Gastroenterology, University of California, San Francisco, San Francisco, California USA
| | - Sachiko M. Oshima
- Division of General Internal Medicine, University of California, San Francisco, San Francisco, California USA
| | - Victoria J. Laleau
- Division of Gastroenterology, University of California, San Francisco, San Francisco, California USA
| | - Carly D. Rachocki
- Division of Gastroenterology, University of California, San Francisco, San Francisco, California USA
| | - Ellen H. Chen
- Department of Public Health, San Francisco, California USA
| | - Lukejohn W. Day
- Division of Gastroenterology, University of California, San Francisco, San Francisco, California USA
| | - Urmimala Sarkar
- Division of General Internal Medicine, University of California, San Francisco, San Francisco, California USA
| | - Ma Somsouk
- Division of Gastroenterology, University of California, San Francisco, San Francisco, California USA
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Dalton ARH. Incomplete diagnostic follow-up after a positive colorectal cancer screening test: a systematic review. J Public Health (Oxf) 2017; 40:e46-e58. [DOI: 10.1093/pubmed/fdw147] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Accepted: 12/20/2016] [Indexed: 12/19/2022] Open
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Martin J, Halm EA, Tiro JA, Merchant Z, Balasubramanian BA, McCallister K, Sanders JM, Ahn C, Bishop WP, Singal AG. Reasons for Lack of Diagnostic Colonoscopy After Positive Result on Fecal Immunochemical Test in a Safety-Net Health System. Am J Med 2017; 130:93.e1-93.e7. [PMID: 27591183 PMCID: PMC5164844 DOI: 10.1016/j.amjmed.2016.07.028] [Citation(s) in RCA: 80] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2016] [Revised: 07/26/2016] [Accepted: 07/26/2016] [Indexed: 12/14/2022]
Abstract
BACKGROUND Effective colorectal cancer screening depends on timely diagnostic evaluation in patients with abnormal results on fecal immunochemical tests (FITs). Although prior studies suggest low rates of follow-up colonoscopy, there is little information among patients in safety-net health systems and few data characterizing reasons for low follow-up rates. This study aimed to characterize factors contributing to lack of follow-up colonoscopy in a racially diverse and socioeconomically disadvantaged cohort of patients with abnormal results on FIT ("abnormal FIT" for brevity) receiving care in an integrated safety-net health system. METHODS We performed a retrospective electronic medical record review of patients aged 50-64 years with abnormal FIT at a population-based safety-net health system between January 2010 and July 2013. Review of electronic medical records focused on patients without follow-up colonoscopy to characterize patient-, provider-, and system-level reasons for lack of diagnostic evaluation. We used logistic regression analysis to identify predictors of follow-up colonoscopy within 12 months of abnormal FIT. RESULTS Of 1267 patients with abnormal FIT, 536 (42.3%) failed to undergo follow-up colonoscopy within 1 year. Failure was attributable to patient-level factors in 307 (57%) cases, provider factors in 97 (18%) cases, and system factors in 118 (22%) cases. In multivariate analysis, follow-up colonoscopy was less likely among those aged 61-64 years (odds ratio 0.63, 95% confidence interval 0.46-0.87) compared with 50-55 year olds. CONCLUSIONS Nearly half (42%) of patients with abnormal FIT failed to undergo follow-up colonoscopy within 1 year. Lack of diagnostic evaluation is related to a combination of patient-, provider-, and system-level factors, highlighting the need for multilevel interventions to improve follow-up colonoscopy completion rates.
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Affiliation(s)
- Jason Martin
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Tex; Parkland Health & Hospital System, Dallas, Tex
| | - Ethan A Halm
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Tex; Parkland Health & Hospital System, Dallas, Tex; Department of Clinical Sciences, UT Southwestern Medical Center, Dallas, Tex; Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, Tex
| | - Jasmin A Tiro
- Department of Clinical Sciences, UT Southwestern Medical Center, Dallas, Tex; Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, Tex
| | - Zahra Merchant
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Tex
| | - Bijal A Balasubramanian
- Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, Tex; Department of Epidemiology, Human Genetics, and Environmental Sciences, UTHealth School of Public Health - Dallas Campus, Dallas, Tex
| | | | - Joanne M Sanders
- Department of Clinical Sciences, UT Southwestern Medical Center, Dallas, Tex
| | - Chul Ahn
- Department of Clinical Sciences, UT Southwestern Medical Center, Dallas, Tex; Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, Tex
| | - Wendy Pechero Bishop
- Department of Clinical Sciences, UT Southwestern Medical Center, Dallas, Tex; Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, Tex
| | - Amit G Singal
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Tex; Parkland Health & Hospital System, Dallas, Tex; Department of Clinical Sciences, UT Southwestern Medical Center, Dallas, Tex; Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, Tex.
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Shahidi N, Cheung WY. Colorectal cancer screening: Opportunities to improve uptake, outcomes, and disparities. World J Gastrointest Endosc 2016; 8:733-740. [PMID: 28042387 PMCID: PMC5159671 DOI: 10.4253/wjge.v8.i20.733] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Revised: 09/05/2016] [Accepted: 09/18/2016] [Indexed: 02/05/2023] Open
Abstract
Colorectal cancer screening has become a standard of care in industrialized nations for those 50 to 75 years of age, along with selected high-risk populations. While colorectal cancer screening has been shown to reduce both the incidence and mortality of colorectal cancer, it is a complex multi-disciplinary process with a number of important steps that require optimization before tangible improvements in outcomes are possible. For both opportunistic and programmatic colorectal cancer screening, poor participant uptake remains an ongoing concern. Furthermore, current screening modalities (such as the guaiac based fecal occult blood test, fecal immunochemical test and colonoscopy) may be used or performed suboptimally, which can lead to missed neoplastic lesions and unnecessary endoscopic evaluations. The latter poses the risk of adverse events, such as perforation and post-polypectomy bleeding, as well as financial impacts to the healthcare system. Moreover, ongoing disparities in colorectal cancer screening persist among marginalized populations, including specific ethnic minorities (African Americans, Hispanics, Asians, Indigenous groups), immigrants, and those who are economically disenfranchised. Given this context, we aimed to review the current literature on these important areas pertaining to colorectal cancer screening, particularly focusing on the guaiac based fecal occult blood test, the fecal immunochemical test and colonoscopy.
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Chubak J, Garcia MP, Burnett-Hartman AN, Zheng Y, Corley DA, Halm EA, Singal AG, Klabunde CN, Doubeni CA, Kamineni A, Levin TR, Schottinger JE, Green BB, Quinn VP, Rutter CM. Time to Colonoscopy after Positive Fecal Blood Test in Four U.S. Health Care Systems. Cancer Epidemiol Biomarkers Prev 2016; 25:344-50. [PMID: 26843520 DOI: 10.1158/1055-9965.epi-15-0470] [Citation(s) in RCA: 91] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND To reduce colorectal cancer mortality, positive fecal blood tests must be followed by colonoscopy. METHODS We identified 62,384 individuals ages 50 to 89 years with a positive fecal blood test between January 1, 2011 and December 31, 2012 in four health care systems within the Population-Based Research Optimizing Screening through Personalized Regimens (PROSPR) consortium. We estimated the probability of follow-up colonoscopy and 95% confidence intervals (CI) using the Kaplan-Meier method. Overall differences in cumulative incidence of follow-up across health care systems were assessed with the log-rank test. HRs and 95% CIs were estimated from multivariate Cox proportional hazards models. RESULTS Most patients who received a colonoscopy did so within 6 months of their positive fecal blood test, although follow-up rates varied across health care systems (P <0.001). Median days to colonoscopy ranged from 41 (95% CI, 40-41) to 174 (95% CI, 123-343); percent followed-up by 12 months ranged from 58.1% (95% CI, 51.6%-63.7%) to 83.8% (95% CI, 83.4%-84.3%) and differences across health care systems were also observed at 1, 2, 3, and 6 months. Increasing age and comorbidity score were associated with lower follow-up rates. CONCLUSION Individual characteristics and health care system were associated with colonoscopy after positive fecal blood tests. Patterns were consistent across health care systems, but proportions of patients receiving follow-up varied. These findings suggest that there is room to improve follow-up of positive colorectal cancer screening tests. IMPACT Understanding the timing of colonoscopy after positive fecal blood tests and characteristics associated with lack of follow-up may inform future efforts to improve follow-up.
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Affiliation(s)
| | | | - Andrea N Burnett-Hartman
- Fred Hutchinson Cancer Research Center, Seattle, Washington. Institute for Health Research, Kaiser Permanente Colorado, Denver, Colorado
| | - Yingye Zheng
- Fred Hutchinson Cancer Research Center, Seattle, Washington
| | | | - Ethan A Halm
- Departments of Internal Medicine and Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Amit G Singal
- Departments of Internal Medicine and Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, Texas
| | | | - Chyke A Doubeni
- Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Partin MR, Shaukat A, Nelson DB, Gravely A, Nugent S, Gellad ZF, Burgess JF. Reply. Clin Gastroenterol Hepatol 2016; 14:486. [PMID: 26689898 DOI: 10.1016/j.cgh.2015.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Melissa R Partin
- Center for Chronic Disease Outcomes Research, Minneapolis Veterans Affairs Health Care System and Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Aasma Shaukat
- Center for Chronic Disease Outcomes Research, Minneapolis Veterans Affairs Health Care System and Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - David B Nelson
- Center for Chronic Disease Outcomes Research, Minneapolis Veterans Affairs Health Care System and Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Amy Gravely
- Center for Chronic Disease Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota
| | - Sean Nugent
- Center for Chronic Disease Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota
| | - Ziad F Gellad
- Durham Veterans Affairs Health Care System and Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - James F Burgess
- Center for Healthcare Organization and Implementation Research, Boston Veterans Affairs Health Care System and Department of Health Policy and Management, Boston University School of Public Health, Boston, Massachusetts
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Correia A, Rabeneck L, Baxter NN, Paszat LF, Sutradhar R, Yun L, Tinmouth J. Lack of follow-up colonoscopy after positive FOBT in an organized colorectal cancer screening program is associated with modifiable health care practices. Prev Med 2015; 76:115-22. [PMID: 25895843 DOI: 10.1016/j.ypmed.2015.03.028] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2014] [Revised: 03/16/2015] [Accepted: 03/21/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND ColonCancerCheck (CCC), Ontario's organized colorectal cancer (CRC) screening program, uses guaiac fecal occult blood testing (gFOBT). To reduce CRC-related mortality, persons with a positive gFOBT must have colonoscopy. We identified factors associated with failure to have colonoscopy within 6months of a positive gFOBT. METHODS Population-based, retrospective cohort analysis of CCC participants with positive gFOBT (April 2008 to December 2009) using health administrative data. Patient, physician and health care utilization factors associated with a lack of follow-up colonoscopy were identified using descriptive and multivariate analyses. RESULTS There were 21,839 participants with a positive gFOBT; 14,091 (64%) had colonoscopy within 6months. The strongest factors associated with failure to follow-up were recent colonoscopy (in 2years prior vs. >10years or never, OR: 4.31, 95% C.I.: 3.82, 4.86), as well as repeat gFOBT (OR: 6.08, 95% C.I.: 5.46, 6.78) and hospital admission (OR: 4.35, 95% C.I.: 3.57, 5.26) in the follow-up period. CONCLUSION In the first 18months of the CCC Program, 1/3 of those with a positive gFOBT did not have colonoscopy within 6months. Identification of potentially modifiable factors associated with failure to follow up lay the groundwork for interventions to address this critical quality gap.
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Affiliation(s)
- Adriano Correia
- Credit Valley Hospital, Trillium Health Partners, Mississauga, Ontario, Canada.
| | - Linda Rabeneck
- Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada; Institute for Clinical Evaluative Sciences, Toronto, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada; Cancer Care Ontario, Toronto, Canada.
| | - Nancy N Baxter
- Institute for Clinical Evaluative Sciences, Toronto, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada; Department of Surgery and Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada; Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada; Department of Surgery, University of Toronto, Toronto, Ontario, Canada.
| | - Lawrence F Paszat
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, Canada; Institute for Clinical Evaluative Sciences, Toronto, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, Canada.
| | - Rinku Sutradhar
- Institute for Clinical Evaluative Sciences, Toronto, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, Canada.
| | - Lingsong Yun
- Institute for Clinical Evaluative Sciences, Toronto, Canada.
| | - Jill Tinmouth
- Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada; Institute for Clinical Evaluative Sciences, Toronto, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada; Cancer Care Ontario, Toronto, Canada; Department of Medicine, University of Toronto, Toronto, Ontario, Canada.
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Leff B, Carlson CM, Saliba D, Ritchie C. The Invisible Homebound: Setting Quality-Of-Care Standards For Home-Based Primary And Palliative Care. Health Aff (Millwood) 2015; 34:21-9. [DOI: 10.1377/hlthaff.2014.1008] [Citation(s) in RCA: 79] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Bruce Leff
- Bruce Leff ( ) is a professor of medicine at the Johns Hopkins University School of Medicine, in Baltimore, Maryland
| | - Charlotte M. Carlson
- Charlotte M. Carlson is an associate medical director at On Lok Senior Health Services, in San Francisco, California
| | - Debra Saliba
- Debra Saliba is director of the University of California, Los Angeles, Borun Center and a research physician in the Veterans Affairs Greater Los Angeles Healthcare System
| | - Christine Ritchie
- Christine Ritchie is a professor in the Department of Medicine at the University of California, San Francisco
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Singal AG, Gupta S, Lee J, Halm EA, Rutter CM, Corley D, Inadomi J. Importance of determining indication for colonoscopy: implications for practice and policy original. Clin Gastroenterol Hepatol 2014; 12:1958-63.e1-3. [PMID: 25606584 PMCID: PMC4303343 DOI: 10.1016/j.cgh.2014.09.028] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Amit G Singal
- Department of Internal Medicine and Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, Texas 75390-8887, USA.
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Lièvre A, Laurent V, Cudennec T, Peschaud F, Malafosse R, Benoist S, Penna C, Lepère C, Vaillant JN, Julié C, Teillet L, Nordlinger B, Rougier P, Mitry E. Management of patients over 80 years of age treated with resection for localised colon cancer: results from a French referral centre. Dig Liver Dis 2014; 46:838-45. [PMID: 24908573 DOI: 10.1016/j.dld.2014.05.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2013] [Revised: 04/14/2014] [Accepted: 05/06/2014] [Indexed: 02/06/2023]
Abstract
BACKGROUND Few data are available on management of very elderly colon cancer patients, especially concerning the parameters of therapeutic decisions and the role of geriatricians. METHODS We retrospectively reviewed the charts of patients over 80 years of age who underwent surgery for a localised colon cancer in a French academic hospital. RESULTS A total of 176 patients underwent surgery (postoperative morbidity and mortality rates: 25% and 6.7%). Adjuvant chemotherapy was discussed at a multidisciplinary team meeting for 91% of stage III patients, but only 13.5% of them were treated. Twenty-five patients relapsed: 19 were discussed at the multidisciplinary meeting and 16 were treated (5 had a metastasectomy). Despite their increase with time, geriatric assessments were infrequent, 17% (33% after 2006), and had no impact on postoperative morbi-mortality. Median overall survival and recurrence-free survival were 65.3 months and 65.1 months, respectively. Age, emergency surgery, and Charlson comorbidity index were independent prognostic factors. CONCLUSION Selected elderly colon cancer patients have significant access to surgery. However, postoperative morbi-mortality rates remain high and adjuvant chemotherapy rarely prescribed. Perioperative geriatric assessment, especially before surgery, should be routinely proposed to these patients to evaluate its impact on postoperative morbi-mortality and prescription of adjuvant treatment.
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Affiliation(s)
- Astrid Lièvre
- Institut Curie, René Huguenin Hospital, Department of Medical Oncology, Saint-Cloud, France; University of Versailles Saint Quentin, Faculty of Health Sciences, Montigny-Le-Bretonneux, France.
| | - Valérie Laurent
- AP-HP, Kremblin-Bicêtre Hospital, Department of Hepato-Gastroenterology and Digestive Oncology, Le Kremlin Bicêtre, France
| | - Tristan Cudennec
- AP-HP, Ambroise Paré Hospital, Department of Geriatrics, Boulogne-Billancourt, France
| | - Frédérique Peschaud
- University of Versailles Saint Quentin, Faculty of Health Sciences, Montigny-Le-Bretonneux, France; AP-HP, Ambroise Paré Hospital, Department of Digestive Surgery and Surgical Oncology, Boulogne-Billancourt, France
| | - Robert Malafosse
- AP-HP, Ambroise Paré Hospital, Department of Digestive Surgery and Surgical Oncology, Boulogne-Billancourt, France
| | - Stéphane Benoist
- AP-HP, Kremlin-Bicêtre Hospital, Department of Digestive Surgery and Surgical Oncology, Le Kremlin Bicêtre, France
| | - Christophe Penna
- AP-HP, Kremlin-Bicêtre Hospital, Department of Digestive Surgery and Surgical Oncology, Le Kremlin Bicêtre, France
| | - Céline Lepère
- AP-HP, Department of Hepato-gastroenterology and Digestive Oncology, Georges Pompidou European Hospital, Paris, France
| | - Jean-Nicolas Vaillant
- AP-HP, Department of Hepato-gastroenterology and Digestive Oncology, Georges Pompidou European Hospital, Paris, France
| | - Catherine Julié
- University of Versailles Saint Quentin, Faculty of Health Sciences, Montigny-Le-Bretonneux, France; AP-HP, Ambroise Paré Hospital, Department of Pathology, Boulogne-Billancourt, France
| | - Laurent Teillet
- University of Versailles Saint Quentin, Faculty of Health Sciences, Montigny-Le-Bretonneux, France; AP-HP, Ambroise Paré Hospital, Department of Geriatrics, Boulogne-Billancourt, France
| | - Bernard Nordlinger
- University of Versailles Saint Quentin, Faculty of Health Sciences, Montigny-Le-Bretonneux, France; AP-HP, Ambroise Paré Hospital, Department of Digestive Surgery and Surgical Oncology, Boulogne-Billancourt, France
| | - Philippe Rougier
- AP-HP, Department of Hepato-gastroenterology and Digestive Oncology, Georges Pompidou European Hospital, Paris, France
| | - Emmanuel Mitry
- Institut Curie, René Huguenin Hospital, Department of Medical Oncology, Saint-Cloud, France; University of Versailles Saint Quentin, Faculty of Health Sciences, Montigny-Le-Bretonneux, France
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