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Durowoju L, Mathias PC, Bell-Brown A, Breit N, Liao HC, Burke W, Issaka RB. Performance of OC-Auto Micro 80 Fecal Immunochemical Test in an Integrated Academic-Community Health System. J Clin Gastroenterol 2024; 58:602-606. [PMID: 37983772 PMCID: PMC10963337 DOI: 10.1097/mcg.0000000000001928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 08/17/2023] [Indexed: 11/22/2023]
Abstract
GOALS We aimed to determine the performance of the OC-Auto Micro 80 fecal immunochemical test (FIT) in an average-risk population receiving care in an integrated, academic-community health system. BACKGROUND The FIT is the most used colorectal cancer (CRC) screening test worldwide. However, many Food and Drug Administration-cleared FIT products have not been evaluated in clinical settings. STUDY We performed a retrospective cohort study of patients (50 to 75 y old) in the University of Washington Medicine health care system who were screened for CRC by OC-Auto Micro 80 FIT between March 2016 and September 2021. We used electronic health records to extract patient-level and clinic-level factors, FIT use, colonoscopy, and pathology findings. The primary outcomes were the FIT positivity rate and neoplasms detected at colonoscopy. Secondary outcomes were FIT positivity by sex and safety-net versus non-safety-net clinical settings. RESULTS We identified 39,984 FITs completed by 26,384 patients; 2411 (6.0%) had a positive FIT result (>100 ng/mL of hemoglobin in buffer), and 1246 (51.7%) completed a follow-up colonoscopy. The FIT positive rate was 7.0% in men and 5.2% in women ( P <0.01). Among those who completed a colonoscopy after an abnormal FIT result, the positive predictive value for CRC, advanced adenoma, and advanced neoplasia was 3.0%, 20.9%, and 23.9%, respectively. CONCLUSIONS In a retrospective analysis of a large heterogeneous population, the OC-Auto Micro 80 FIT for CRC screening demonstrated a positivity rate of 6.0% and a positive predictive value for CRC of 3.0%.
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Affiliation(s)
| | - Patrick C. Mathias
- Departments of Laboratory Medicine and Pathology
- Biomedical Informatics and Medical Education, University of Washington School of Medicine
| | - Ari Bell-Brown
- Hutchinson Institute for Cancer Outcomes Research, Fred Hutchinson Cancer Center
| | - Nathan Breit
- Departments of Laboratory Medicine and Pathology
| | | | - Wynn Burke
- Public Health Sciences & Clinical Research Divisions, Fred Hutchinson Cancer Center, Seattle, WA
| | - Rachel B. Issaka
- Division of Gastroenterology, University of Washington School of Medicine
- Hutchinson Institute for Cancer Outcomes Research, Fred Hutchinson Cancer Center
- Public Health Sciences & Clinical Research Divisions, Fred Hutchinson Cancer Center, Seattle, WA
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Lee JY, Pihl E, Kim HK, Russell T, Petrie BA, Lee H. Risk Factors for Suboptimal Colon Cancer Diagnosis and Management at a Safety-Net Hospital System. J Surg Res 2024; 301:127-135. [PMID: 38925099 DOI: 10.1016/j.jss.2024.05.036] [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: 02/29/2024] [Revised: 05/07/2024] [Accepted: 05/16/2024] [Indexed: 06/28/2024]
Abstract
INTRODUCTION Colon cancer (CC) is the second leading cause of cancer-related deaths in the United States. Quality measures have been introduced by the American Gastroenterological Association and Commission on Cancer for optimal management of CC. In this study, we sought to identify factors that may hinder the timely diagnosis and treatment of CC at a safety-net hospital system. METHODS Retrospective chart review was performed for patients aged ≥18 y diagnosed with CC from 2018 to 2021. Primary outcomes were time from positive fecal immunochemical test to colonoscopy, time from diagnosis to surgery, and time from diagnosis to adjuvant chemotherapy. Secondary end points were demographic characteristics associated with suboptimal outcomes in any of the above measures. RESULTS One hundred ninety patients were diagnosed with nonmetastatic CC. The majority were Hispanic and non-English-speaking. 74.1% of patients with a positive fecal immunochemical test received a colonoscopy within 180 d. 59.6% of nonemergent cases received surgery within 60 d of diagnosis. 77% of those eligible received adjuvant chemotherapy within 120 d of diagnosis. No clinically significant demographic factor was associated with delay in colonoscopy, surgery, or adjuvant chemotherapy. Most frequent cause of delay in surgery (38.0%) was optimization of comorbidities. Most frequent cause of delay in adjuvant chemotherapy (71.4%) was delay in surgery itself. CONCLUSIONS No clinically significant demographic factor was associated with experiencing delays in diagnostic colonoscopy, surgery, or adjuvant chemotherapy.
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Affiliation(s)
- Ju Young Lee
- David Geffen School of Medicine, UCLA, Los Angeles, California
| | - Erik Pihl
- Division of Colon and Rectal Surgery, Harbor-UCLA Medical Center, Torrance, California
| | - Hye Kwang Kim
- Midwestern University Chicago College of Osteopathic Medicine, Downers Grove, Illinois
| | - Tara Russell
- Division of Colon and Rectal Surgery, Olive View-UCLA Medical Center, Sylmar, California
| | - Beverley A Petrie
- Division of Colon and Rectal Surgery, Harbor-UCLA Medical Center, Torrance, California
| | - Hanjoo Lee
- Division of Colon and Rectal Surgery, Harbor-UCLA Medical Center, Torrance, California.
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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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Robertson DJ, Rex DK, Ciani O, Drummond MF. Colonoscopy vs the Fecal Immunochemical Test: Which is Best? Gastroenterology 2024; 166:758-771. [PMID: 38342196 DOI: 10.1053/j.gastro.2023.12.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 12/18/2023] [Accepted: 12/29/2023] [Indexed: 02/13/2024]
Abstract
Although there is no debate around the effectiveness of colorectal cancer screening in reducing disease burden, there remains a question regarding the most effective and cost-effective screening modality. Current United States guidelines present a panel of options that include the 2 most commonly used modalities, colonoscopy and stool testing with the fecal immunochemical test (FIT). Large-scale comparative effectiveness trials comparing colonoscopy and FIT for colorectal cancer outcomes are underway, but results are not yet available. This review will separately state the "best case" for FIT and colonoscopy as the screening tool of first choice. In addition, the review will examine these modalities from a health economics perspective to provide the reader further context about the relative advantages of these commonly used tests.
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Affiliation(s)
- Douglas J Robertson
- VA Medical Center, White River Junction, Vermont; Geisel School of Medicine at Dartmouth, Hanover, New Hampshire.
| | - Douglas K Rex
- Division of Gastroenterology/Hepatology, Indiana University School of Medicine, Indianapolis, Indiana
| | - Oriana Ciani
- Centre for Research on Health and Social Care Management, SDA Bocconi School of Management, Milan, Italy
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Shareef F, Bharti B, Garcia-Bigley F, Hernandez M, Nodora J, Liu J, Ramers C, Nery JD, Marquez J, Moyano K, Rojas S, Arredondo E, Gupta S. Abnormal Colorectal Cancer Test Follow-Up: A Quality Improvement Initiative at a Federally Qualified Health Center. J Prim Care Community Health 2024; 15:21501319241242571. [PMID: 38554066 PMCID: PMC10981848 DOI: 10.1177/21501319241242571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Revised: 03/07/2024] [Accepted: 03/08/2024] [Indexed: 04/01/2024] Open
Abstract
INTRODUCTION/OBJECTIVES Colonoscopy completion rates after an abnormal fecal immunochemical test (FIT) are suboptimal, resulting in missed opportunities for early detection and prevention of colorectal cancer. Patient navigation and structured follow-up may improve colonoscopy completion, but implementation of these strategies is not widespread. METHODS We conducted a quality improvement study using a Plan-Do-Study-Act (PDSA) Model to increase colonoscopy completion after abnormal FIT in a large federally qualified health center serving a diverse and low-income population. Intervention components included patient navigation, and a checklist to promote completion of key steps required for abnormal FIT follow-up. Primary outcome was proportion of patients achieving colonoscopy completion within 6 months of abnormal FIT, assessed at baseline for 156 patients pre-intervention, and compared to 208 patients during the intervention period from April 2017 to December 2019. Drop offs at each step in the follow-up process were assessed. RESULTS Colonoscopy completion improved from 21% among 156 patients with abnormal FIT pre-intervention, to 38% among 208 patients with abnormal FIT during the intervention (P < .001; absolute increase: 17%, 95% CI: 6.9%-25.2%). Among the 130 non-completers during the intervention period, lack of completion was attributable to absence of colonoscopy referral for 7.7%; inability to schedule a pre-colonoscopy specialist visit for 71.5%; failure to complete a pre-colonoscopy visit for 2.3%; the absence of colonoscopy scheduling for 9.2%; failure to show for a scheduled colonoscopy for 9.2%. CONCLUSIONS Patient navigation and structured follow-up appear to improve colonoscopy completion after abnormal FIT. Additional strategies are needed to achieve optimal rates of completion.
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Affiliation(s)
- Faizah Shareef
- University of California San Diego (Internal Medicine), La Jolla, CA, USA
| | - Balambal Bharti
- University of California San Diego (Internal Medicine), La Jolla, CA, USA
| | | | | | - Jesse Nodora
- University of California San Diego (Radiation Medicine), La Jolla, CA, USA
- Moores Cancer Center, University of California San Diego, La Jolla, CA, USA
| | - Jie Liu
- Shang Consulting LLC, San Diego CA, USA
| | - Christian Ramers
- Family Health Centers of San Diego (Graduate Medical Education), San Diego, CA, USA
| | | | | | - Karina Moyano
- Moores Cancer Center, University of California San Diego, La Jolla, CA, USA
| | | | | | - Samir Gupta
- University of California San Diego (Internal Medicine), La Jolla, CA, USA
- Moores Cancer Center, University of California San Diego, La Jolla, CA, USA
- Veterans Affairs San Diego Healthcare System, San Diego, CA, USA
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Kwok K, Levin TR, Dominitz JA, Panganamamula K, Feld AD, Bardall B, Newbury K, Day LW. Transportation barriers and endoscopic procedures: barriers, legal challenges, and strategies for GI endoscopy units. Gastrointest Endosc 2023; 98:475-481. [PMID: 37632487 DOI: 10.1016/j.gie.2023.05.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 05/09/2023] [Indexed: 08/28/2023]
Affiliation(s)
- Karl Kwok
- Department of Gastroenterology, Kaiser Permanente, Los Angeles Medical Center, Los Angeles, California, USA
| | - Theodore R Levin
- Division of Gastroenterology, Kaiser Permanente Medical Center, Walnut Creek, California, USA
| | - Jason A Dominitz
- Department of Medicine, Division of Gastroenterology, University of Washington, Seattle, Washington, USA
| | - Kashyap Panganamamula
- Division of Gastroenterology, Department of Medicine, University of Pennsylvania, Penn Presbyterian Medical Center, Philadelphia, Pennsylvania, USA
| | - Andrew D Feld
- Division of Gastroenterology, Kaiser Permanente and Division of Medicine, University of Washington, Seattle, Washington, USA
| | - Bruce Bardall
- The Joint Commission, Oakbrook Terrace, Illinois, USA
| | - Kara Newbury
- Ambulatory Surgery Center Association, Alexandria, Virginia, USA
| | - Lukejohn W Day
- Division of Gastroenterology, Department of Medicine, Zuckerberg San Francisco General Hospital and University of San Francisco, San Francisco, California, USA
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Wang CP, Miller SJ, Shaukat A, Jandorf LH, Greenwald DA, Itzkowitz SH. Blood-based colorectal cancer screening: are we ready for the next frontier? Lancet Gastroenterol Hepatol 2023; 8:870-872. [PMID: 37482062 PMCID: PMC10529001 DOI: 10.1016/s2468-1253(23)00188-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 06/08/2023] [Accepted: 06/09/2023] [Indexed: 07/25/2023]
Affiliation(s)
- Christina P Wang
- Dr Henry D Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York City, NY 10029, USA.
| | - Sarah J Miller
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York City, NY 10029, USA
| | - Aasma Shaukat
- Division of Gastroenterology, Department of Medicine, New York University Grossman School of Medicine, New York City, NY, USA
| | - Lina H Jandorf
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York City, NY 10029, USA
| | - David A Greenwald
- Dr Henry D Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York City, NY 10029, USA
| | - Steven H Itzkowitz
- Dr Henry D Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York City, NY 10029, USA
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Liang PS, Zaman A, Kaminsky A, Cui Y, Castillo G, Tenner CT, Sherman SE, Dominitz JA. Blood Test Increases Colorectal Cancer Screening in Persons Who Declined Colonoscopy and Fecal Immunochemical Test: A Randomized Controlled Trial. Clin Gastroenterol Hepatol 2023; 21:2951-2957.e2. [PMID: 37037262 PMCID: PMC10523873 DOI: 10.1016/j.cgh.2023.03.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Revised: 03/21/2023] [Accepted: 03/29/2023] [Indexed: 04/12/2023]
Abstract
BACKGROUND & AIMS The septin 9 blood test is indicated for colorectal cancer screening in individuals who decline first-line tests, but participation in this context is unclear. We conducted a randomized controlled trial to compare reoffering colonoscopy and fecal immunochemical test (FIT) alone versus also offering the blood test among individuals who declined colonoscopy and FIT. METHODS Screen-eligible Veterans aged 50-75 years who declined colonoscopy and FIT within the previous 6 months were randomized to letter and telephone outreach to reoffer screening with colonoscopy/FIT only (control), or additionally offering the blood test as a second-line option (intervention). The primary outcome was completion of any screening test within 6 months. The secondary outcome was completion of a full screening strategy within 6 months, including colonoscopy for those with a positive noninvasive test. RESULTS Of 359 participants who completed follow-up, 9.6% in the control group and 17.1% in the intervention group completed any screening (7.5% difference; P = .035). Uptake of colonoscopy and FIT was similar in the 2 groups. The full screening strategy was completed in 9.0% and 14.9% in the control and intervention groups, respectively (5.9% difference; P = .084). CONCLUSIONS Among individuals who previously declined colonoscopy and FIT, offering a blood test as a secondary option increased screening by 7.5% without decreasing uptake of first-line screening options. However, completion of a full screening strategy did not increase. These findings indicate that a blood test is a promising method to improve colorectal cancer screening, but obtaining a timely colonoscopy after a positive noninvasive test remains a challenge (ClincialTrials.gov number, NCT03598166).
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Affiliation(s)
- Peter S Liang
- Department of Medicine, VA New York Harbor Health Care System, New York, New York; Department of Medicine, NYU Langone Health, New York, New York.
| | - Anika Zaman
- Department of Medicine, VA New York Harbor Health Care System, New York, New York; Department of Medicine, NYU Langone Health, New York, New York
| | - Anne Kaminsky
- Department of Medicine, VA New York Harbor Health Care System, New York, New York
| | - Yongyan Cui
- Department of Medicine, NYU Langone Health, New York, New York
| | | | - Craig T Tenner
- Department of Medicine, VA New York Harbor Health Care System, New York, New York; Department of Medicine, NYU Langone Health, New York, New York
| | - Scott E Sherman
- Department of Medicine, VA New York Harbor Health Care System, New York, New York; Department of Medicine, NYU Langone Health, New York, New York
| | - Jason A Dominitz
- Department of Medicine, VA Puget Sound Health Care System, Seattle, Washington; Department of Medicine, University of Washington School of Medicine, Seattle, Washington
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Nagpal N, McCready TM, Xia Y, Lin K, Glenn M, Ng S, Trinh-Shevrin C, Troxel AB, Kwon SC, Liang PS. Predictors of Colonoscopy Use Among Asian Indians in New York City, 2003 to 2016. J Clin Gastroenterol 2023:00004836-990000000-00194. [PMID: 37556383 PMCID: PMC10853482 DOI: 10.1097/mcg.0000000000001900] [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: 04/25/2023] [Accepted: 07/06/2023] [Indexed: 08/11/2023]
Abstract
BACKGROUND Asian Americans have the lowest colorectal cancer screening uptake of any racial and ethnic group in the United States. Asian Indians are among the most under-screened Asian American subgroups, but there is limited data for this population. We sought to characterize predictors of colonoscopy use among Asian Indians in New York City. METHODS Using 2003 to 2016 data from the New York City Community Health Survey, we identified all Asian Indian participants aged 50 years or older. We examined the association between sociodemographic and medical factors and up-to-date colonoscopy use (defined as colonoscopy within the last 10 y) using logistic regression over 4 time periods: 2003 to 2008, 2009 to 2012, 2013 to 2014, 2015 to 2016. RESULTS On multivariable analysis, language, age, income, recent exercise, body mass index, and influenza vaccination were associated with colonoscopy uptake in 1 time period. Compared with participants who preferred English, those who preferred an Indian language were less likely to have been up-to-date in 2013 to 2014 (odds ratio 0.12, 95% CI 0.02-0.66). Individuals older than 65 years were more likely than those aged 50 to 64 years to have received a colonoscopy in 2009 to 2012 (odds ratio 3.91, 95% CI 1.49-10.24), although the risk estimates were also consistently positive in the other 3 time periods. CONCLUSIONS Among Asian Indians living in New York City, several demographic, socioeconomic, and health-related characteristics predict colonoscopy use. These findings highlight the importance of examining determinants of colonoscopy uptake in this understudied population to inform future public health interventions.
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Affiliation(s)
- Neha Nagpal
- Department of Medicine, NYU Grossman School of Medicine, New York, New York, United States of America
| | - Taylor M. McCready
- Department of Population Health, NYU Grossman School of Medicine, New York, New York, United States of America
| | - Yuhe Xia
- Department of Population Health, NYU Grossman School of Medicine, New York, New York, United States of America
| | - Kevin Lin
- Department of Medicine, NYU Grossman School of Medicine, New York, New York, United States of America
| | - Matthew Glenn
- NYU Grossman School of Medicine, New York, New York, United States of America
| | - Sandy Ng
- Department of Medicine, NYU Grossman School of Medicine, New York, New York, United States of America
| | - Chau Trinh-Shevrin
- Department of Medicine, NYU Grossman School of Medicine, New York, New York, United States of America
- Department of Population Health, NYU Grossman School of Medicine, New York, New York, United States of America
| | - Andrea B. Troxel
- Department of Population Health, NYU Grossman School of Medicine, New York, New York, United States of America
| | - Simona C. Kwon
- Department of Medicine, NYU Grossman School of Medicine, New York, New York, United States of America
- Department of Population Health, NYU Grossman School of Medicine, New York, New York, United States of America
| | - Peter S. Liang
- Department of Medicine, NYU Grossman School of Medicine, New York, New York, United States of America
- Department of Population Health, NYU Grossman School of Medicine, New York, New York, United States of America
- Department of Medicine, Veteran Affairs New York Harbor Health Care System, New York, New York, United States of America
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Segura A, Siddique SM. Reducing disparities and achieving health equity in colorectal cancer screening. TECHNIQUES AND INNOVATIONS IN GASTROINTESTINAL ENDOSCOPY 2023; 25:284-296. [PMID: 37808233 PMCID: PMC10554575 DOI: 10.1016/j.tige.2023.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/10/2023]
Abstract
Increases in colorectal cancer screening are linked to the declining incidence of the disease over the past three decades. These favorable trends, however, are not observed in marginalized racial and ethnic populations with disproportionately lower rates of screening, higher disease incidence, and increased mortality despite advances in health technology and policy. This review describes the differences in screening uptake and test selection amongst racial and ethnic groups, discusses known obstacles and facilitators that impact screening, and highlights existing frameworks developed to achieve health equity in colorectal cancer screening.
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Affiliation(s)
- Abraham Segura
- Division of Gastroenterology, University of Pennsylvania
| | - Shazia Mehmood Siddique
- Division of Gastroenterology, University of Pennsylvania
- Leonard Davis Institute for Health Economics, University of Pennsylvania
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11
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Liu PH, Sanford NN, Liang PS, Singal AG, Murphy CC. Persistent Disparities in Colorectal Cancer Screening: A Tell-Tale Sign for Implementing New Guidelines in Younger Adults. Cancer Epidemiol Biomarkers Prev 2022; 31:1701-1709. [PMID: 35765830 PMCID: PMC9444917 DOI: 10.1158/1055-9965.epi-21-1330] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 02/11/2022] [Accepted: 05/09/2022] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND In May 2021, the U.S. Preventive Services Task Force began recommending initiating colorectal cancer screening at age 45 (vs. 50) years. METHODS We estimated prevalence of colorectal cancer screening (by colonoscopy, sigmoidoscopy, CT colonography, or stool-based tests) in adults ages 50 to 75 years using data from the National Health Interview Survey in 2000, 2003, 2005, 2008, 2010, 2013, 2015, and 2018. For each survey year, we estimated prevalence by age, race/ethnicity, educational attainment, family income, and health insurance. We also compared increases in prevalence of screening from 2000 to 2018 in 5-year age groups (50-54, 55-59, 60-64, 65-69, and 70-75 years). RESULTS Overall, prevalence of colorectal cancer screening increased from 36.7% in 2000 to 66.1% in 2018. Screening prevalence in 2018 was lowest for age 50 to 54 years (47.6%), Hispanics (56.5%), Asians (57.1%), and participants with less than a high school degree (53.6%), from low-income families (56.6%), or without insurance (39.7%). Increases in prevalence over time differed by five-year age group. For example, prevalence increased from 28.2% in 2000 to 47.6% in 2018 (+19.4%; 95% CI, 13.1-25.6) for age 50 to 54 years but from 46.4% to 78.0% (+31.6%; 95% CI, 25.4%-37.7%) for age 70 to 75 years. This pattern was consistent across race/ethnicity, educational attainment, family income, and health insurance. CONCLUSIONS Prevalence of colorectal cancer screening remains low in adults ages 50 to 54 years. IMPACT As new guidelines are implemented, care must be taken to ensure screening benefits are realized equally by all population groups, particularly newly eligible adults ages 45 to 49 years. See related commentary by Brawley, p. 1671.
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Affiliation(s)
- Po-Hong Liu
- Division of Digestive and Liver Diseases, Department of Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Nina N. Sanford
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, TX
| | - Peter S. Liang
- Department of Medicine, NYU Langone Health, New York, NY,Department of Medicine, VA New York Harbor Health Care System, New York, NY
| | - Amit G. Singal
- Division of Digestive and Liver Diseases, Department of Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Caitlin C. Murphy
- School of Public Health, University of Texas Health Science Center at Houston, Houston, TX
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12
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Wercholuk AN, Parikh AA, Snyder RA. The Road Less Traveled: Transportation Barriers to Cancer Care Delivery in the Rural Patient Population. JCO Oncol Pract 2022; 18:652-662. [DOI: 10.1200/op.22.00122] [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] Open
Abstract
Patients with cancer residing in geographically rural areas experience lower rates of preventative screening, more advanced disease at presentation, and higher mortality rates compared with urban populations. Although multiple factors contribute, access to transportation has been proposed as a critical barrier affecting timeliness and quality of health care delivery in rural populations. Patients from geographically rural regions may face a variety of transportation barriers, including lack of public transportation, limited access to private vehicles, and increased travel distance to specialized oncologic care. A search using PubMed was conducted to identify articles pertaining to transportation barriers to cancer care and tested interventions in rural patient populations. Studies demonstrate that transportation barriers are associated with delayed follow-up after abnormal screening test results, decreased access to specialized oncology care, and lower rates of receipt of guideline-concordant treatment. Low clinical trial enrollment and variability in survivorship care are also linked to transportation barriers in rural patient populations. Given the demonstrated impact of transportation access on equitable cancer care delivery, several interventions have been tested. Telehealth visits and outreach clinics appear to reduce patient travel burden and increase access to specialized care, and patient navigation programs are effective in connecting patients with local resources, such as free or subsidized nonemergency medical transportation. To ensure equal access to high-quality cancer care and reduce geographic disparities, the design and implementation of tailored, multilevel interventions to address transportation barriers affecting rural communities is critical.
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Affiliation(s)
- Ashley N. Wercholuk
- Division of Surgical Oncology, Department of Surgery, Brody School of Medicine at East Carolina University, Greenville, NC
| | - Alexander A. Parikh
- Division of Surgical Oncology, Department of Surgery, Brody School of Medicine at East Carolina University, Greenville, NC
| | - Rebecca A. Snyder
- Division of Surgical Oncology, Department of Surgery, Brody School of Medicine at East Carolina University, Greenville, NC
- Department of Public Health, Brody School of Medicine at East Carolina University, Greenville, NC
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Issaka RB, Bell-Brown A, Kao J, Snyder C, Atkins DL, Chew LD, Weiner BJ, Strate L, Inadomi JM, Ramsey SD. Barriers Associated with Inadequate Follow-up of Abnormal Fecal Immunochemical Test Results in a Safety-Net System: A Mixed-Methods Analysis. Prev Med Rep 2022; 28:101831. [PMID: 35637893 PMCID: PMC9144348 DOI: 10.1016/j.pmedr.2022.101831] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Revised: 05/09/2022] [Accepted: 05/15/2022] [Indexed: 01/05/2023] Open
Abstract
Less than 50% of patients with an abnormal FIT result had a documented reason. Patient-level (e.g., declined colonoscopy) reasons were most frequently documented. Interviews revealed discordance in documented and patient-reported reasons. Mixed-methods analyses are needed to improve colonoscopy after abnormal FIT results.
In safety-net healthcare systems, colonoscopy completion within 1-year of an abnormal fecal immunochemical test (FIT) result rarely exceeds 50%. Understanding how electronic health records (EHR) documented reasons for missed colonoscopy match or differ from patient-reported reasons, is critical to optimize effective interventions to address this challenge. We conducted a convergent mixed-methods study which included a retrospective analysis of EHR data and semi-structured interviews of adults 50–75 years old, with abnormal FIT results between 2014 and 2020 in a large safety-net healthcare system. Of the 299 patients identified, 59.2% (n = 177) did not complete a colonoscopy within one year of their abnormal result. EHR abstraction revealed a documented reason for lack of follow-up colonoscopy in 49.2% (n = 87/177); patient-level (e.g., declined colonoscopy; 51.5%) and multi-factorial reasons (e.g., lost to follow-up; 37.9%) were most common. In 18 patient interviews, patient (e.g., fear of colonoscopy), provider (e.g., lack of result awareness), and system-level reasons (e.g., scheduling challenges) were most common. Only three reasons for lack of colonoscopy overlapped between EHR data and patient interviews (competing health issues, lack of transportation, and abnormal FIT result attributed to another cause). In a cohort of safety-net patients with abnormal FIT results, the most common reasons for lack of follow-up were patient-related. Our analysis revealed a discordance between EHR documented and patient-reported reasons for lack of colonoscopy after an abnormal FIT result. Mixed-methods analyses, as in the present study, may give us the greatest insight into modifiable determinants to develop effective interventions beyond quantitative and qualitative data analysis alone.
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Affiliation(s)
- Rachel B. Issaka
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
- Hutchinson Institute for Cancer Outcomes Research, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
- Division of Gastroenterology, University of Washington School of Medicine, Seattle, WA, USA
- Corresponding author at: 1100 Fairview Ave. N., M/S: M3-B232, Seattle, WA 98109, USA
| | - Ari Bell-Brown
- Hutchinson Institute for Cancer Outcomes Research, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Jason Kao
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
- Seattle Cancer Care Alliance, Division of Medical Oncology, Seattle, WA, USA
| | - Cyndy Snyder
- Department of Family Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - Dana L. Atkins
- Hutchinson Institute for Cancer Outcomes Research, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Lisa D. Chew
- Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - Bryan J. Weiner
- Department of Health Services, University of Washington School of Public Health, Seattle, WA, USA
| | - Lisa Strate
- Division of Gastroenterology, University of Washington School of Medicine, Seattle, WA, USA
| | - John M. Inadomi
- Department of Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Scott D. Ramsey
- Hutchinson Institute for Cancer Outcomes Research, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
- Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA
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Mog AC, Liang PS, Donovan LM, Sayre GG, Shaukat A, May FP, Glorioso TJ, Jorgenson MA, Wood GB, Mueller C, Dominitz JA. Timely Colonoscopy After Positive Fecal Immunochemical Tests in the Veterans Health Administration: A Qualitative Assessment of Current Practice and Perceived Barriers. Clin Transl Gastroenterol 2022; 13:e00438. [PMID: 35060937 PMCID: PMC8865517 DOI: 10.14309/ctg.0000000000000438] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Accepted: 11/04/2021] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION The Veterans Health Administration introduced a clinical reminder system in 2018 to help address process gaps in colorectal cancer screening, including the diagnostic evaluation of positive fecal immunochemical test (FIT) results. We conducted a qualitative study to explore the differences between facilities who performed in the top vs bottom decile for follow-up colonoscopy. METHODS Seventeen semistructured interviews with gastroenterology (GI) providers and staff were conducted at 9 high-performing and 8 low-performing sites. RESULTS We identified 2 domains, current practices and perceived barriers, and most findings were described by both high- and low-performing sites. Findings exclusive to 1 group mainly pertained to current practices, especially arranging colonoscopy for FIT-positive patients. We observed only 1 difference in the perceived barriers domain, which pertained to primary care providers. DISCUSSION These results suggest that what primarily distinguishes high- and low-performing sites is not a difference in barriers but rather in the GI clinical care process. Developing and disseminating patient education materials about the importance of diagnostic colonoscopy, eliminating in-person precolonoscopy visits when clinically appropriate, and involving GI in missed colonoscopy appointments and outside referrals should all be considered to increase follow-up colonoscopy rates. Our study illustrates the challenges of performing a timely colonoscopy after a positive FIT result and provides insights on improving the clinical care process for patients who are at substantially increased risk for colorectal cancer.
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Affiliation(s)
- Ashley C. Mog
- Veteran Affairs Puget Sound Healthcare System, Seattle, Washington, USA
- University of Washington, Seattle, Washington, USA
| | - Peter S. Liang
- Veteran Affairs New York Harbor Healthcare System, New York, New York, USA
- NYU Langone Health, New York, New York, USA
| | - Lucas M. Donovan
- Veteran Affairs Puget Sound Healthcare System, Seattle, Washington, USA
- University of Washington, Seattle, Washington, USA
| | - George G. Sayre
- Veteran Affairs Puget Sound Healthcare System, Seattle, Washington, USA
- University of Washington, Seattle, Washington, USA
| | - Aasma Shaukat
- Minneapolis Veteran Affairs Healthcare System, Minneapolis, Minnesota, USA
- University of Minnesota, Minneapolis, Minnesota, USA
| | - Folasade P. May
- Veteran Affairs Greater Los Angeles Healthcare System, Los Angeles, California, USA
- University of California, Los Angeles, California, USA
| | - Thomas J. Glorioso
- CART Program, Office of Quality and Patient Safety, Veterans Health Administration, Washington, DC, USA
| | | | - Gordon Blake Wood
- Veteran Affairs Puget Sound Healthcare System, Seattle, Washington, USA
| | - Candice Mueller
- CART Program, Office of Quality and Patient Safety, Veterans Health Administration, Washington, DC, USA
| | - Jason A. Dominitz
- Veteran Affairs Puget Sound Healthcare System, Seattle, Washington, USA
- University of Washington, Seattle, Washington, USA
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Bell-Brown A, Chew L, Weiner BJ, Strate L, Balmadrid B, Lewis CC, Hannon P, Inadomi JM, Ramsey SD, Issaka RB. Operationalizing a Rideshare Intervention for Colonoscopy Completion: Barriers, Facilitators, and Process Recommendations. FRONTIERS IN HEALTH SERVICES 2022; 1:799816. [PMID: 35128543 PMCID: PMC8817893 DOI: 10.3389/frhs.2021.799816] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Transportation is a common barrier to colonoscopy completion for colorectal cancer (CRC) screening. The study aims to identify the barriers, facilitators, and process recommendations to implement a rideshare non-emergency medical transportation (NEMT) intervention following colonoscopy completion within a safety-net healthcare setting. METHODS We used informal stakeholder engagement, story boards - a novel user-centered design technique, listening sessions and the nominal group technique to identify the barriers, facilitators, and process to implementing a rideshare NEMT program following colonoscopy completion in a large safety-net healthcare system. RESULTS Barriers to implementing a rideshare NEMT intervention for colonoscopy completion included: inability to expand an existing NEMT program beyond Medicaid patients and lack of patient chaperones with rideshare NEMT programs. Facilitators included: commercially available rideshare NEMT platforms that were lower cost and had shorter wait times than the alternative of taxis. Operationalizing and implementing a rideshare NEMT intervention in our healthcare system required the following steps: 1) identifying key stakeholders, 2) engaging stakeholder groups in discussion to identify barriers and solutions, 3) obtaining institutional sign-off, 4) developing a process for reviewing and selecting a rideshare NEMT program, 5) executing contracts, 6) developing a standard operating procedure and 7) training clinic staff to use the rideshare platform. DISCUSSION Rideshare NEMT after procedural sedation is administered may improve colonoscopy completion rates and provide one solution to inadequate CRC screening. If successful, our rideshare model could be broadly applicable to other safety-net health systems, populations with high social needs, and settings where procedural sedation is administered.
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Affiliation(s)
- Ari Bell-Brown
- Hutchinson Institute for Cancer Outcomes Research, Fred Hutchinson Cancer Research Center, Seattle, WA, United States
| | - Lisa Chew
- Department of Internal medicine, University of Washington School of Medicine, Seattle, WA, United States
| | - Bryan J Weiner
- Department of Health Systems and Population Health, University of Washington School of Public Health, Seattle, WA, United States
| | - Lisa Strate
- Division of Gastroenterology, University of Washington School of Medicine, Seattle, WA, United States
| | - Bryan Balmadrid
- Division of Gastroenterology, University of Washington School of Medicine, Seattle, WA, United States
| | - Cara C Lewis
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, United States
| | - Peggy Hannon
- Department of Health Systems and Population Health, University of Washington School of Public Health, Seattle, WA, United States
| | - John M Inadomi
- Department of Medicine, University of Utah School of Medicine, Salt Lake City, UT, United States
| | - Scott D Ramsey
- Hutchinson Institute for Cancer Outcomes Research, Fred Hutchinson Cancer Research Center, Seattle, WA, United States.,Department of Internal medicine, University of Washington School of Medicine, Seattle, WA, United States
| | - Rachel B Issaka
- Hutchinson Institute for Cancer Outcomes Research, Fred Hutchinson Cancer Research Center, Seattle, WA, United States.,Division of Gastroenterology, University of Washington School of Medicine, Seattle, WA, United States.,Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, United States
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