Diagnostic colonoscopy following a positive fecal occult blood test in community health center patients

Limited English proficiency and reported receipt of colorectal cancer screening among adults 45-75 in 2019 and 2021

Introduction

Substantial barriers to screening exist for medically underserved populations, especially adults with limited English proficiency (LEP). We examined the proportion of US adults aged 45-75 up-to-date with colorectal cancer (CRC) screening by LEP after 2018. The American Cancer Society began recommending CRC screening for adults 45-49 in 2018.

Methods

We analyzed cross-sectional data of adults 45-75 years old participating in the 2019 or 2021 National Health Interview Survey (N = 25,611). Adults were considered up-to-date with screening if they reported any stool test within 1 year, stool-DNA testing within 3 years, or colonoscopy within 10 years. Adults who interviewed in a language other than English were considered to have LEP. Adults not up-to-date with screening were asked if a healthcare professional (HCP) recommended screening, and if so which test(s). Regression models conducted in 2022-2023 evaluated receipt of screening, adjusting for sociodemographics, year, and healthcare access.

Results

Overall, 54.0 % (95 % CI 53.1-54.9 %) of participants were up-to-date with screening (9.4 % aged 45-49 vs 75.5 % aged 65-75); prevalence increased from 2019 (52.9 %) to 2021(55.2 %). Adults with LEP (vs English proficiency) were less likely to be up-to-date with screening (31.6 % vs. 56.8 %, [aPR 0.86 (0.77-0.96)]). Among adults not up-to-date, 15.0 % reported their HCP recommended screening (8.4 % among adults with LEP).

Conclusions

Nearly half of US adults were not up-to-date with CRC screening in 2019 and 2021 and few reported being recommended screening. Adults with LEP and those 45-49 were least likely to be screened suggesting targeted interventions are needed for these populations.

The recalibration and redevelopment of a model to calculate patients' probability of completing a colonoscopy following an abnormal fecal test

OBJECTIVES

Fecal immunochemical testing (FIT) is an effective screening tool for colorectal cancer. If an FIT is abnormal, a follow-up colonoscopy is necessary to remove polyps or find cancers. We sought to develop a usable risk prediction model to identify patients unlikely to complete a colonoscopy following an abnormal FIT test.

METHODS

We recalibrated and then redeveloped a prediction model in federally qualified health centers (FQHCs), using a retrospective cohort of patients aged 50-75 with an abnormal FIT test and clinical data. Logistic and Cox regressions were used to recalibrate and then redevelop the model.

RESULTS

The initial risk model used data from eight FQHCs (26 clinics) including 1723 patients. When we applied the model to a single large FQHC (34 clinics, 884 eligible patients), the model did not recalibrate successfully (c-statistic dropped more than 0.05, from 0.66 to 0.61). The model was redeveloped in the same FQHC in a cohort of 1401 patients with a c-statistic of 0.65.

CONCLUSIONS

The original model developed in a group of FQHCs did not adequately recalibrate in the single large FQHC. Health system, patient characteristics or data differences may have led to the inability to recalibrate the model. However, the redeveloped model provides an adequate model for the single FQHC.

Developing Patient-Refined Messaging for Follow-Up Colonoscopy After Abnormal Fecal Testing in Hispanic Communities: Key Learnings from Virtual Boot Camp Translation

Colorectal cancer (CRC) is a leading cause of cancer death in the US. Screening by fecal immunochemical test (FIT) is a strategy to lower CRC rates. Unfortunately, only half of patients with an abnormal FIT result complete the follow-up colonoscopy, an essential component of screening. We used virtual Boot Camp Translation (BCT), to elicit input from partners to develop messaging/materials to motivate patients to complete a follow-up colonoscopy. Participants were Hispanic, ages 50 to 75 years, and Spanish-speaking. All materials were developed in English and Spanish. The first meeting included expert presentations that addressed colorectal health. The two follow-up sessions obtained feedback on messaging/materials developed based on themes from the first meeting. Ten participants attended the first meeting and eight attended the follow-up sessions. The two key barriers to follow-up colonoscopy after abnormal FIT noted by participants were (a) lack of colonoscopy awareness and (b) fear of the colonoscopy procedure. We learned that participants valued simple messaging to increase knowledge and alleviate concerns, patient-friendly outreach materials, and increased access to health information. Using virtual BCT, we included participant feedback to design culturally relevant health messages to promote follow-up colonoscopy after abnormal fecal testing among Hispanic patients served by community clinics.

Equitable Implementation of Mailed Stool Test-Based Colorectal Cancer Screening and Patient Navigation in a Safety Net Health System

BACKGROUND

Mailed stool testing programs increase colorectal cancer (CRC) screening in diverse settings, but whether uptake differs by key demographic characteristics is not well-studied and has health equity implications.

OBJECTIVE

To examine the uptake and equity of the first cycle of a mailed stool test program implemented over a 3-year period in a Central Texas Federally Qualified Health Center (FQHC) system.

DESIGN

Retrospective cohort study within a single-arm intervention.

PARTICIPANTS

Patients in an FQHC aged 50-75 at average CRC risk identified through electronic health records (EHR) as not being up to date with screening.

INTERVENTIONS

Mailed outreach in English/Spanish included an introductory letter, free-of-charge fecal immunochemical test (FIT), and lab requisition with postage-paid mailer, simple instructions, and a medical records update postcard. Patients were asked to complete the FIT or postcard reporting recent screening. One text and one letter reminded non-responders. A bilingual patient navigator guided those with positive FIT toward colonoscopy.

MAIN MEASURES

Proportions of patients completing mailed FIT in response to initial cycle of outreach and proportion of those with positive FIT completing colonoscopy; comparison of whether proportions varied by demographics and insurance status obtained from the EHR.

KEY RESULTS

Over 3 years, 33,606 patients received an initial cycle of outreach. Overall, 19.9% (n = 6672) completed at least one mailed FIT, 5.6% (n = 374) tested positive during that initial cycle, and 72.5% (n = 271 of 374) of those with positive FIT completed a colonoscopy. Hispanic/Latinx, Spanish-speaking, and uninsured patients were more likely to complete mailed FIT compared with white, English-speaking, and commercially insured patients. Spanish-speaking patients were more likely to complete colonoscopy after positive FIT compared with English-speaking patients.

CONCLUSIONS

Mailed FIT outreach with patient navigation implemented in an FQHC system was effective in equitably reaching patients not up to date for CRC screening.

Colonoscopy Following an Abnormal Fecal Test Result from an Annual Colorectal Cancer Screening Program in a Federally Qualified Health Center

OBJECTIVE

Individuals with an abnormal fecal immunochemical test (FIT) result have an elevated risk of colorectal cancer, and the risk increases if the follow-up colonoscopy is delayed. Of note, rates of follow-up colonoscopy are alarmingly low in federally qualified health centers (FQHCs), US health care settings that serve a majority racial and ethnic minority patient population. We assessed factors associated with colonoscopy after an abnormal FIT result and used chart-abstracted data to assess reasons (including process measures) for lack of follow-up as part of an annual, mailed-FIT outreach program within a large, Latino-serving FQHC.

METHODS

As part of the National Institutes of Health-funded PROMPT study, we identified patients with an abnormal FIT result and used logistic regression to assess associations between patient demographics and receipt of follow-up colonoscopy, controlling for patients' preferred language. We report on time (days) to referral and time to colonoscopy. For charts with an abnormal FIT result but no evidence of colonoscopy, we performed a manual abstraction and obtained the reason for the absence of colonoscopy. When there was no evidence of colonoscopy in a patient's electronic health record (EHR), we performed an automated query of the administrative claims database to identify colonoscopy outcomes.

RESULTS

We identified 324 patients with abnormal FIT results from July to October 2018. These patients were mostly publicly insured (Medicaid 53.1%, Medicare 14.5%), 81.8% were aged 50 to 64 years, 55.3% were female, 80.3% were Hispanic/Latino, and 67.3% preferred to speak Spanish. We found that 108/324 (33.3%) patients completed colonoscopy within 12 months, and the median time to colonoscopy was 94 days (IQR: 68-176). Common barriers to colonoscopy completion, obtained from chart-abstracted data, were: no documentation following referral to gastrointestinal (GI) specialist or GI consultation (41.6%), no referral to GI specialist following abnormal fecal test (34.2%), and absence of a valid insurance authorization (6.5%).

CONCLUSIONS

Multi-level strategies are needed to provide optimal care across the cancer continuum for FQHC patients. In order to reduce the risk of CRC and realize the return on fecal testing investment, concerted system-level efforts are urgently needed to improve rates of follow-up colonoscopy among FQHC patients and redress racial and ethnic disparities in CRC screening outcomes.

Disparities in Colorectal Cancer Screening in Latinos and Non-Hispanic Whites

INTRODUCTION

Colorectal cancer is the second leading cause of cancer deaths in Latinos in the U.S., but it is unclear, from previous research, whether Latinos have differing rates of colorectal cancer screening methods from those of non-Hispanic Whites.

METHODS

This study used electronic health records from 686 community health centers across 21 states in the Accelerating Data Value Across a National Community Health Center of the National Patient-Centered Clinical Research Network. Records from English-preferring Latinos, Spanish-preferring Latinos, and non-Hispanic Whites aged 50-75 years were included. A total of 5 outcomes were compared between 2012 and 2017 to provide a comprehensive view of colorectal cancer screening: (1) any colorectal cancer screening, (2) stool-based screening, (3) annual rates of stool testing, (4) any referral for lower gastrointestinal endoscopy, and (5) endoscopy referral among patients with a positive stool-based screening.

RESULTS

In this study (N=204,243), Spanish-preferring Latinos had higher odds of any colorectal cancer screening (OR=1.44, 95% CI=1.23, 1.68) and stool-based testing (OR=1.82, 95% CI=1.55, 2.13) than non-Hispanic Whites. English- and Spanish-preferring Latinos had lower odds of having ever had a referral for endoscopy in the study period than non-Hispanic Whites (English: OR=0.23, 95% CI=0.15, 0.34; Spanish: OR=0.55, 95% CI=0.40, 0.74), even with a positive stool-based screening (English: OR=0.14, 95% CI=0.06, 0.33; Spanish: OR=0.33, 95% CI=0.19, 0.57).

CONCLUSIONS

In a multistate network of community health centers, Latino patients aged >50 years were more likely to receive stool-based screening tests for colorectal cancer than non-Hispanic Whites but were less likely to receive endoscopy referrals than non-Hispanic Whites, even when experiencing a positive stool-based screening test. Initiatives to improve Latino colorectal cancer outcomes should encourage indicated referrals for lower gastrointestinal endoscopy.

Colorectal Cancer Screening and Yield in a Mailed Outreach Program in a Safety-Net Healthcare System

BACKGROUND

Screening with fecal immunochemical testing (FIT) reduces colorectal cancer mortality; however, screening remains low in underserved populations. Mailed outreach, including an invitation letter, FIT, and test instructions, is an evidence-based strategy to improve screening.

AIMS

To examine screening completion and yield in a mailed outreach program in a safety-net healthcare system.

METHODS

We identified and mailed outreach invitations to patients due for screening in a large safety-net system between September 1, 2018, and August 31, 2019. We examined: (1) screening completion, the proportion of patients completing FIT or screening colonoscopy within 6 months of the mailed invitation; and (2) timely diagnostic colonoscopy, the proportion of patients completing colonoscopy within 6 months of positive FIT.

RESULTS

We mailed 14,879 invitations to 13,190 patients. Nearly half (n = 6098, 46.2%) of patients completed screening: 4,896 (80.3%) completed FIT through mailed outreach; 1,114 (18.3%) FIT through usual care; and 88 (1.4%) screening colonoscopy through usual care. Of patients with a positive FIT (n = 289), 50.5% completed diagnostic colonoscopy within 6 months, 10.7% within 6-12 months, and 4.8% after 12 months. A total of 8 cancers and 83 advanced adenomas were detected in the 191 patients completing diagnostic colonoscopy.

CONCLUSION

After implementing and scaling up mailed outreach in a safety-net system, about half of patients completed screening, and the majority did so through mailed outreach. However, many patients failed to complete diagnostic colonoscopy after positive FIT. Results highlight the importance of adapting mailed outreach programs to local contexts and constraints of healthcare systems, in order to support efforts to improve CRC screening in underserved populations.

Centralized colorectal cancer screening outreach and patient navigation for vulnerable populations in North Carolina: study protocol for the SCORE randomized controlled trial

BACKGROUND

Although colorectal cancer (CRC) screening is effective in reducing CRC mortality, screening rates in vulnerable populations served by community health centers (CHCs) remain below national targets. CHCs in North Carolina are challenged to reach CRC screening targets as they tend to be under-resourced, have limited capacity to implement and sustain population health interventions, and typically operate independently from one another and from regional colonoscopy providers. The Scaling Colorectal Cancer Screening Through Outreach, Referral, and Engagement (SCORE) project is designed to address barriers to CRC screening in partnership with CHCs by implementing a multilevel intervention that includes centralized support infrastructure for mailed fecal immunochemical test (FIT) outreach and patient navigation to follow-up colonoscopy. This paper describes protocols for the SCORE implementation trial.

METHODS

We will conduct a type 2 hybrid effectiveness-implementation trial that will assess effectiveness at increasing CRC screening and follow-up rates while also assessing implementation outcomes. The planned trial sample will include 4000 CHC patients who are at average CRC risk and due for screening. Participants will be randomized 1:1 to receive either usual care or a multilevel intervention that includes mailed FIT outreach and patient navigation support to follow-up colonoscopy for those with abnormal FIT. The primary effectiveness outcome is completion of any CRC screening test at six months after randomization. We will also conduct a multilevel assessment of implementation outcomes and determinants.

DISCUSSION

This hybrid effectiveness-implementation trial will evaluate the effectiveness and implementation of an intervention that provides centralized infrastructure for mailed FIT screening and patient navigation for CHCs that operate independently of other healthcare facilities. Findings from this research will enhance understanding of the effectiveness of a centralized approach and factors that determine successful implementation in vulnerable patient populations.

TRIAL REGISTRATION

The trial was registered on May 28, 2020, at ClinicalTrials.gov (identifier NCT04406714).

Follow-up colonoscopy after an abnormal stool-based colorectal cancer screening result: analysis of steps in the colonoscopy completion process

Background

Delays in receiving follow-up colonoscopy after an abnormal fecal immunochemical test (FIT) result are associated with increased colorectal cancer incidence and mortality. Little is known about patterns of follow-up colonoscopy completion in federally qualified health centers.

Methods

We abstracted the medical records of health center patients, aged 50–75 years, who had an abnormal FIT result between August 5, 2017 and August 4, 2018 (N = 711). We assessed one-year rates of colonoscopy referral, pre-procedure visit completion, colonoscopy completion, and time to colonoscopy; associations between these outcomes and patient characteristics; and reasons for non-completion found in the medical record.

Results

Of the 711 patients with an abnormal FIT result, 90% were referred to colonoscopy, but only 52% completed a pre-procedure visit, and 43% completed a colonoscopy within 1 year. Median time to colonoscopy was 83 days (interquartile range: 52–131 days). Pre-procedure visit and colonoscopy completion rates were relatively low in patients aged 65–75 (vs. 50–64), who were uninsured (vs. insured) or had no clinic visit in the prior year (vs. ≥ 1 clinic visit). Common reasons listed for non-completion were that the patient declined, or the provider could not reach the patient.

Discussion

Efforts to improve follow-up colonoscopy rates in health centers might focus on supporting the care transition from primary to specialty gastroenterology care and emphasize care for older uninsured patients and those having no recent clinic visits. Our findings can inform efforts to improve follow-up colonoscopy uptake, reduce time to colonoscopy receipt, and save lives from colorectal cancer.

Trial registration: National Clinical Trial (NCT) Identifier: NCT03925883.

The COVID-19 Pandemic: Identifying Adaptive Solutions for Colorectal Cancer Screening in Underserved Communities

The 2019 novel coronavirus disease (COVID-19) pandemic has dramatically impacted numerous health and economic fronts. Because of the stay-at-home mandate and practice of physical distancing, nearly all preventive care measures have been halted, including colorectal cancer (CRC) screening. The health consequences of this temporary suspension are of great concern, particularly for underserved populations, who experience substantial CRC-related disparities. In this commentary, we describe challenges and opportunities to deliver COVID-19-adapted CRC screening to medically underserved populations receiving care in community health centers (CHC). This perspective is based on key informant interviews with CHC medical directors, teleconference discussions, and strategic planning assessments. To address the unprecedented challenges created by the COVID-19 pandemic, we identify 2 broad calls to action: invest in CHCs now and support equitable and adaptable telehealth solutions now and in the future. We also recommend 4 CRC-specific calls to action: establish COVID-19-adapted best practices to implement mailed fecal immunochemical test programs, implement grassroots advocacy to identify community gastroenterologists who commit to performing colonoscopies for CHC patients, assess cancer prevention priorities among individuals in underserved communities, and assess regional CRC screening and follow-up barriers and solutions. The COVID-19 pandemic may further exacerbate existing CRC screening disparities in underserved individuals. This will likely lead to delayed diagnosis, a shift to later-stage disease, and increased CRC deaths. To prevent this from happening, we call for timely action and a commitment to address the current extraordinary CRC screening challenges for vulnerable populations.

Screening for Colorectal Cancer in the United States: Correlates and Time Trends by Type of Test

BACKGROUND

It is strongly recommended that adults aged 50-75 years be screened for colorectal cancer. Recommended screening options include colonoscopy, sigmoidoscopy, CT colonography, guaiac fecal occult blood testing (FOBT), fecal immunochemical testing (FIT), or the more recently introduced FIT-DNA (FIT in combination with a stool DNA test). Colorectal cancer screening programs can benefit from knowledge of patterns of use by test type and within population subgroups.

METHODS

Using 2018 National Health Interview Survey (NHIS) data, we examined colorectal cancer screening test use for adults aged 50-75 years (N = 10,595). We also examined time trends in colorectal cancer screening test use from 2010-2018.

RESULTS

In 2018, an estimated 66.9% of U.S. adults aged 50-75 years had a colorectal cancer screening test within recommended time intervals. However, the prevalence was less than 50% among those aged 50-54 years, those without a usual source of health care, those with no doctor visits in the past year, and those who were uninsured. The test types most commonly used within recommended time intervals were colonoscopy within 10 years (61.1%), FOBT or FIT in the past year (8.8%), and FIT-DNA within 3 years (2.7%). After age-standardization to the 2010 census population, the percentage up-to-date with CRC screening increased from 61.2% in 2015 to 65.3% in 2018, driven by increased use of stool testing, including FIT-DNA.

CONCLUSIONS

These results show some progress, driven by a modest increase in stool testing. However, colorectal cancer testing remains low in many population subgroups.

IMPACT

These results can inform efforts to achieve population colorectal cancer screening goals.

Development of a multivariable prediction model to identify patients unlikely to complete a colonoscopy following an abnormal FIT test in community clinics

Background

Colorectal cancer (CRC) is the 3rd leading cancer killer among men and women in the US. The Strategies and Opportunities to STOP Colon Cancer in Priority Populations (STOP CRC) project aimed to increase CRC screening among patients in Federally Qualified Health Centers (FQHCs) through a mailed fecal immunochemical test (FIT) outreach program. However, rates of completion of the follow-up colonoscopy following an abnormal FIT remain low. We developed a multivariable prediction model using data available in the electronic health record to assess the probability of patients obtaining a colonoscopy following an abnormal FIT test.

Methods

To assess the probability of obtaining a colonoscopy, we used Cox regression to develop a risk prediction model among a retrospective cohort of patients with an abnormal FIT result.

Results

Of 1596 patients with an abnormal FIT result, 556 (34.8%) had a recorded colonoscopy within 6 months. The model shows an adequate separation of patients across risk levels for non-adherence to follow-up colonoscopy (bootstrap-corrected C-statistic > 0.63). The refined model included 8 variables: age, race, insurance, GINI income inequality, long-term anticoagulant use, receipt of a flu vaccine in the past year, frequency of missed clinic appointments, and clinic site. The probability of obtaining a follow-up colonoscopy within 6 months varied across quintiles; patients in the lowest quintile had an estimated 18% chance, whereas patients in the top quintile had a greater than 55% chance of obtaining a follow-up colonoscopy.

Conclusions

Knowing who is unlikely to follow-up on an abnormal FIT test could help identify patients who need an early intervention aimed at completing a follow-up colonoscopy.

Trial registration

This trial was registered at ClinicalTrials.gov (NCT01742065) on December 5, 2012. The protocol is available.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-020-05883-2.

Mailed fecal immunochemical test outreach for colorectal cancer screening: Summary of a Centers for Disease Control and Prevention-sponsored Summit

Uptake of colorectal cancer screening remains suboptimal. Mailed fecal immunochemical testing (FIT) offers promise for increasing screening rates, but optimal strategies for implementation have not been well synthesized. In June 2019, the Centers for Disease Control and Prevention convened a meeting of subject matter experts and stakeholders to answer key questions regarding mailed FIT implementation in the United States. Points of agreement included: 1) primers, such as texts, telephone calls, and printed mailings before mailed FIT, appear to contribute to effectiveness; 2) invitation letters should be brief and easy to read, and the signatory should be tailored based on setting; 3) instructions for FIT completion should be simple and address challenges that may lead to failed laboratory processing, such as notation of collection date; 4) reminders delivered to initial noncompleters should be used to increase the FIT return rate; 5) data infrastructure should identify eligible patients and track each step in the outreach process, from primer delivery through abnormal FIT follow-up; 6) protocols and procedures such as navigation should be in place to promote colonoscopy after abnormal FIT; 7) a high-quality, 1-sample FIT should be used; 8) sustainability requires a program champion and organizational support for the work, including sufficient funding and external policies (such as quality reporting requirements) to drive commitment to program investment; and 9) the cost effectiveness of mailed FIT has been established. Participants concluded that mailed FIT is an effective and efficient strategy with great potential for increasing colorectal cancer screening in diverse health care settings if more widely implemented.

Prospective Cohort study of Predictors of Follow-Up Diagnostic Colonoscopy from a Pragmatic Trial of FIT Screening

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.

Patient randomized trial of a targeted navigation program to improve rates of follow-up colonoscopy in community health centers

BACKGROUND

Colorectal cancer (CRC) screening by annual fecal immunochemical test (FIT) is an accessible and cost-effective strategy to lower CRC incidence and mortality. However, this mode of screening depends on follow-up colonoscopy after a positive FIT result. Unfortunately, nearly one-half of FIT-positive patients fail to complete this essential screening component. Patient navigation may improve follow-up colonoscopy adherence. To deliver patient navigation cost-effectively, health centers could target navigation to patients who are unlikely to complete the procedure on their own.

OBJECTIVES

The Predicting and Addressing Colonoscopy Non-adherence in Community Settings (PRECISE) clinical trial will validate a risk model of follow-up colonoscopy adherence and test whether patient navigation raises rates of colonoscopy adherence overall and among patients in each probability stratum (low, moderate, and high probability of adherence without intervention).

METHODS

PRECISE is a collaboration with a large community health center whose patient population is 37% Latino. Eligible patients will be aged 50-75, have an abnormal FIT result in the past month, and be due for a follow-up colonoscopy. Patients will be randomized to patient navigation or usual care. Primary outcomes will be colonoscopy completion within one year of a positive FIT result, cost, and cost-effectiveness. Secondary outcomes will include time to colonoscopy receipt, adequacy of bowel prep, and communication of results to primary care providers. Primary and secondary outcomes will be reported overall and by probability stratum.

DISCUSSION

This innovative clinical trial will test the effectiveness and financial feasibility of using a precision health intervention to improve CRC screening completion in community health centers.

TRIAL REGISTRATION

National Clinical Trial (NCT) Identifier: NCT03925883.

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?

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.

Direct-to-member mailed colorectal cancer screening outreach for Medicaid and Medicare enrollees: Implementation and effectiveness outcomes from the BeneFIT study

Background

Colorectal cancer screening uptake is low, particularly among individuals enrolled in Medicaid. To the authors' knowledge, little is known regarding the effectiveness of direct‐to‐member outreach by Medicaid health insurance plans to raise colorectal cancer screening use, nor how best to deliver such outreach.

Methods

BeneFIT is a hybrid implementation‐effectiveness study of 2 program models that health plans developed for a mailed fecal immunochemical test (FIT) intervention. The programs differed with regard to whether they used a centralized approach (Health Plan Washington) or collaborated with health centers (Health Plan Oregon). The primary implementation outcome of the current study was the percentage of eligible enrollees to whom the plans delivered each intervention component. The primary effectiveness outcome was the rate of FIT completion within 6 months of mailing of the introductory letter.

Results

The health plans identified 12,000 eligible enrollees (8551 in Health Plan Washington and 3449 in Health Plan Oregon). Health Plan Washington mailed an introductory letter and FIT kit to 8551 enrollees (100%) and delivered a reminder call to 839 (10.3% of the 8132 attempted). Health Plan Oregon mailed an introductory letter, and a letter and FIT kit plus a reminder postcard to 2812 enrollees (81.5%) and 2650 enrollees (76.8%), respectively. FIT completion rates were 18.2% (1557 of 8551 enrollees) in Health Plan Washington. In Health Plan Oregon, completion rates were 17.4% (488 of 2812 enrollees) among enrollees who were mailed an introductory letter and 18.3% (484 of 2650 enrollees) among enrollees who also were mailed a FIT kit plus reminder postcard.

Conclusions

The implementation of mailed FIT outreach by health plans may be effective and could reach many individuals at risk of developing colorectal cancer.

Colorectal cancer screening uptake is low, particularly among individuals enrolled in Medicaid. The implementation of mailed fecal immunochemical test outreach among health plans may be effective and could reach many individuals at risk of developing colorectal cancer.

Colorectal, cervical and prostate cancer screening in Australians with severe mental illness: Retrospective nation-wide cohort study

OBJECTIVE

People with severe mental illness have similar cancer incidence, but higher mortality than the general population. Participation in cancer screening may be a contributing factor but existing studies are conflicting. The aim of this study was to investigate the frequency of colorectal, prostate and cervical cancer screening among people with and without severe mental illness in Australia, who have access to universal health care.

METHODS

We followed three cohorts using de-identified data from a random 10% sample of people registered for Australia's universal health care system: those aged 50-69 years ( n = 760,058) for colorectal cancer screening; women aged 18-69 years ( n = 918,140) for cervical cancer screening and men aged 50-69 years ( n = 380,238) for prostate cancer screening. We used Poisson regression to estimate incidence rate ratios and 95% confidence intervals for the association between severe mental illness and rates of faecal occult blood testing, pap smears and prostate-specific antigen testing.

RESULTS

Having severe mental illness was associated with a 17% reduction in rates of pap smear (incidence rate ratio = 0.83, 95% confidence interval: 0.82-0.84) and prostate-specific antigen testing (incidence rate ratio = 0.83, 95% confidence interval: 0.81-0.85), compared to the general population. By contrast, incidence rates of faecal occult blood testing were only lower in people with severe mental illness among the participants who visited their general practitioner less than an average of five times per year (incidence rate ratio = 0.83, 95% confidence interval = [0.73, 0.94]).

CONCLUSION

Our results suggest that differences in screening frequency may explain some of the mismatch between cancer incidence and mortality in people with severe mental illness and indicate that action is required to improve preventive screening in this very disadvantaged group.

Repeated Automated Mobile Text Messaging Reminders for Follow-Up of Positive Fecal Occult Blood Tests: Randomized Controlled Trial

Background

Fecal occult blood tests (FOBTs) are recommended by the US Preventive Services Task Force as a screening method for colorectal cancer (CRC), but they are only effective if positive results are followed by colonoscopy. Surprisingly, a large proportion of patients with a positive result do not follow this recommendation.

Objective

The objective of this study was to examine the effectiveness of text messaging (short message service, SMS) in increasing adherence to colonoscopy follow-up after a positive FOBT result.

Methods

This randomized controlled trial was conducted with patients who had positive CRC screening results. Randomization was stratified by residential district and socioeconomic status (SES). Subjects in the control group (n=238) received routine care that included an alert to the physician regarding the positive FOBT result. The intervention group (n=232) received routine care and 3 text messaging SMS reminders to visit their primary care physician. Adherence to colonoscopy was measured 120 days from the positive result. All patient information, including test results and colonoscopy completion, were obtained from their electronic medical records. Physicians of study patients completed an attitude survey regarding FOBT as a screening test for CRC. Intervention and control group variables (dependent and independent) were compared using chi-square test. Logistic regression was used to calculate odds ratios (ORs) and 95% CIs for performing colonoscopy within 120 days for the intervention group compared with the control group while adjusting for potential confounders including age, gender, SES, district, ethnicity, and physicians’ attitude.

Results

Overall, 163 of the 232 patients in the intervention group and 112 of the 238 patients in the control group underwent colonoscopy within 120 days of the positive FOBT results (70.3% vs 47.1%; OR 2.17, 95% CI 1.49-3.17; P<.001); this association remained significant after adjusting for potential confounders (P=.001).

Conclusions

A text message (SMS) reminder is an effective, simple, and inexpensive method for improving adherence among patients with positive colorectal screening results. This type of intervention could also be evaluated for other types of screening tests.

Trial Registration

ClinicalTrials.gov NCT03642652; https://clinicaltrials.gov/ct2/show/NCT03642652 (Archived by WebCite at http://www.webcitation.org/74TlICijl)

Predictors of Colorectal Cancer Screening Prior to Implementation of a Large Pragmatic Trial in Federally Qualified Health Centers

Colorectal cancer screening can prevent cancer deaths. Federally qualified health centers serve a unique patient population that often is not screened. Knowing who in this environment is getting screened via fecal testing and via colonoscopy can assist in tailoring intervention to raise rates of colorectal cancer screening. We examined patient-level and neighborhood-level characteristics associated with being up to date with colorectal cancer screening guidelines. We also examined associations between these factors and being screened with a fecal test. We observed an increase in colorectal cancer screening rates from 2010 to 2015. Adjusted analyses revealed that the following factors were significantly associated with colorectal cancer screening: aged 65 or older, having any type of insurance, previous outpatient visits, and current or other preventive screenings. Among adults aged 50-75 who were up to date with colorectal cancer screening, factors associated with use of fecal testing, as opposed to colonoscopy, were: being younger, speaking a non-English language, being uninsured, having prior office visits, and having had a flu shot in past year. Our findings may inform clinic-based effort to raise rates of colorectal cancer screening, especially in the community clinic setting.

TRIAL REGISTRATION

ClinicalTrials.gov , NCT01742065.

Is the patient activation measure associated with adherence to colonoscopy after a positive fecal occult blood test result?

BACKGROUND

Colorectal cancer (CRC) is a major cause of morbidity and mortality worldwide, but these can be reduced significantly with population screening using annual fecal occult blood tests (FOBT)A positive FOBT requires timely follow-up with colonoscopy to maximize screening benefits.. Several barriers to follow-up have been identified, with patient health behaviors and choices comprising a significant part of these. The Patient Activation Measure (PAM) assesses knowledge, skills, beliefs, and confidence in managing health. Increased patient activation is related to positive health outcomes. The aim of this study is to examine the association between patient empowerment, as reflected in the PAM, and follow-up colonoscopy within 90 days of a positive FOBT result.

METHODS

This case-control study included 429 patients with a positive FOBT, 174 who had a colonoscopy within 90 days, and 255 who did not.. Participants completed a PAM telephone questionnaire (Cronbach's α = 0.785). We used both univariate and multivariate analyses to examine the effect of the PAM score as on the likelihood of undergoing colonoscopy, after adjusting for the independent variables.

RESULTS

In this study we did not find a significant association between PAM and adherence to colonoscopy, using both univariate and multivariate analyses (p = .334 and p = .697, whether PAM was defined as a continuous or as categorical, respectively).

CONCLUSIONS

This study was the first to examine the association between patient empowerment, as reflected in the patient activation measure, and adherence to colonoscopy after a positive FOBT. The findings did not support such an association. Further examination is required to clarify the relation between patient empowerment and activation and personal healthcare in general, and in the Israeli population in particular. Future policy should include specific, technical interventions to improve FOBT follow-up among all groups, until the patient-related barriers are better understood.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02534142 https://clinicaltrials.gov/ct2/show/NCT02534142.

A motivational phone call improves participation to screening colonoscopy for those with a positive FIT in a national screening programme (NCT 03276091)

BACKGROUND

A large proportion of individuals with a positive faecal immunologic test (FIT) will never undergo the recommended colonoscopy despite a full sequence of reminders.

AIMS

This prospective study aimed to recruit refractory individuals by a motivational personalised phone call given by a screening physician.

METHODS

We evaluated the impact of a motivational phone call given by a physician of the screening organisation in order to convince patients with positive FIT to undergo a colonoscopy.

RESULTS

115 individuals with a positive FIT were targeted. After GP phone call, it was ascertained that 15 had had a colonoscopy, one died, one moved outside the region, and the GP refused the study phone call for 13. Finally, we attempted to call 85 individuals; 24 could not be reached, 5 colonoscopies had been performed, and thus 56 individuals were included. The main reason for colonoscopy refusal (33.9%) was wrong advice from the GP or the gastroenterologist. Among those included, 33.9% (19/56) underwent the colonoscopy within 22.7 months after FIT; 1 invasive cancer, 18 adenomas and 9 serrated sessile lesions were found.

CONCLUSION

Motivational phone call performed by a physician from the screening organisation is effective to recruit a third of refractory individuals. Education for GPs and gastroenterologists is necessary to increase participation to colonoscopy and to avoid the performance of an inappropriate secondary FIT.

TRIAL REGISTRATION

NCT 03276091.

Demographic and comorbidity predictors of adherence to diagnostic colonoscopy in the Danish Colorectal Cancer Screening Program: a nationwide cross-sectional study

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.

Contribution of patient, physician, and environmental factors to demographic and health variation in colonoscopy follow-up for abnormal colorectal cancer screening test results

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.