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Cusumano VT, Myint A, Corona E, Yang L, Bocek J, Lopez AG, Huang MZ, Raja N, Dermenchyan A, Roh L, Han M, Croymans D, May FP. Patient Navigation After Positive Fecal Immunochemical Test Results Increases Diagnostic Colonoscopy and Highlights Multilevel Barriers to Follow-Up. Dig Dis Sci 2021; 66:3760-3768. [PMID: 33609211 DOI: 10.1007/s10620-021-06866-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 01/20/2021] [Indexed: 12/31/2022]
Abstract
BACKGROUND The fecal immunochemical test (FIT) is a common colorectal cancer screening modality in the USA but often is not followed by diagnostic colonoscopy. AIMS We investigated the efficacy of patient navigation to increase diagnostic colonoscopy after positive FIT results and determined persistent barriers to follow-up despite navigation in a large, academic healthcare system. METHODS The study cohort included all health system outpatients with an assigned primary care provider, a positive FIT result between 12/01/2016 and 06/01/2019, and no documentation of colonoscopy after positive FIT. Two non-clinical patient navigators engaged patients and providers to encourage follow-up, offer solutions to barriers, and assist with colonoscopy scheduling. The primary intervention endpoint was completion of colonoscopy within 6 months of navigation. We documented reasons for persistent barriers to colonoscopy despite navigation and determined predictors of successful follow-up after navigation. RESULTS There were 119 patients who received intervention. Of these, 37 (31.1%) patients completed colonoscopy at 6 months. In 41/119 (34.5%) cases, the PCP did not recommend colonoscopy, most commonly due to a normal colonoscopy prior to the positive FIT (19, 46.3%). There were 41/119 patients (34.5%) that declined colonoscopy despite the patient navigator and the PCP order. Male sex and younger age were significant predictors of follow-up (aOR = 2.91, 95%CI, 1.18-7.13; aOR = 0.92, 95%CI, 0.87-0.99). CONCLUSIONS After implementation of patient navigation, diagnostic colonoscopy was completed for 31.1% of patients with a positive FIT result. However, navigation also highlighted persistent multilevel barriers to follow-up. Future work will develop targeted solutions for these barriers to further increase FIT follow-up rates in our health system.
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Affiliation(s)
- Vivy T Cusumano
- Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, 650 Charles Young Drive South, Room A2-125 CHS, Los Angeles, CA, 90095-6900, USA.,Vatche and Tamar Manoukian Division of Digestive Diseases, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Anthony Myint
- Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, 650 Charles Young Drive South, Room A2-125 CHS, Los Angeles, CA, 90095-6900, USA.,Vatche and Tamar Manoukian Division of Digestive Diseases, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Edgar Corona
- Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, 650 Charles Young Drive South, Room A2-125 CHS, Los Angeles, CA, 90095-6900, USA.,Vatche and Tamar Manoukian Division of Digestive Diseases, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Liu Yang
- Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, 650 Charles Young Drive South, Room A2-125 CHS, Los Angeles, CA, 90095-6900, USA.,Vatche and Tamar Manoukian Division of Digestive Diseases, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Jennifer Bocek
- Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, 650 Charles Young Drive South, Room A2-125 CHS, Los Angeles, CA, 90095-6900, USA.,Faculty Practice Group and Office of Population Health and Accountable Care, University of California Los Angeles, Los Angeles, CA, USA
| | - Antonio G Lopez
- Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, 650 Charles Young Drive South, Room A2-125 CHS, Los Angeles, CA, 90095-6900, USA
| | - Marcela Zhou Huang
- Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, 650 Charles Young Drive South, Room A2-125 CHS, Los Angeles, CA, 90095-6900, USA
| | - Naveen Raja
- Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, 650 Charles Young Drive South, Room A2-125 CHS, Los Angeles, CA, 90095-6900, USA.,Faculty Practice Group and Office of Population Health and Accountable Care, University of California Los Angeles, Los Angeles, CA, USA
| | - Anna Dermenchyan
- Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, 650 Charles Young Drive South, Room A2-125 CHS, Los Angeles, CA, 90095-6900, USA.,Quality Program, Department of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Lily Roh
- Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, 650 Charles Young Drive South, Room A2-125 CHS, Los Angeles, CA, 90095-6900, USA.,Faculty Practice Group and Office of Population Health and Accountable Care, University of California Los Angeles, Los Angeles, CA, USA
| | - Maria Han
- Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, 650 Charles Young Drive South, Room A2-125 CHS, Los Angeles, CA, 90095-6900, USA.,Quality Program, Department of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Daniel Croymans
- Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, 650 Charles Young Drive South, Room A2-125 CHS, Los Angeles, CA, 90095-6900, USA.,Quality Program, Department of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Folasade P May
- Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, 650 Charles Young Drive South, Room A2-125 CHS, Los Angeles, CA, 90095-6900, USA. .,Vatche and Tamar Manoukian Division of Digestive Diseases, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA. .,Cancer Prevention Control Research, UCLA Kaiser Permanente Center for Health Equity, Jonsson Comprehensive Cancer Center, University of California, Los Angeles, CA, USA. .,Department of Medicine, Division of Gastroenterology, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA.
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Labaeka EO, Irabor AE, Irabor DO. Fecal Immunochemical Test as a Screening Method for Colorectal Cancer in University College Hospital Ibadan, Nigeria. JCO Glob Oncol 2021; 6:525-531. [PMID: 32216652 PMCID: PMC7113128 DOI: 10.1200/jgo.19.00340] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
PURPOSE Colorectal cancer (CRC) is a disease of public health importance because of the increasing incidence of the disease and presentation in advanced stage of the disease in Western Africa. CRC is amenable to screening because of the long course of premalignant lesions before final development of the disease. Despite this, the practice of CRC screening is inadequate at the sites in this study. The fecal immunochemical test (FIT) is one of the recommended noninvasive methods for CRC screening. It has a sensitivity of 96%, specificity of 90%, and an overall accuracy of 95%. We aimed to determine the practicability of FIT for CRC screening in patients aged 40 to 75 years who attended primary care clinics in the University College Hospital, Ibadan, Nigeria. PATIENTS AND METHODS A total of 422 patients selected by systematic random sampling were recruited and offered free FIT screening. Participants with a positive finding had additional GI examination, including a digital rectal examination, proctoscopy, and colonoscopy, if no lesion was biopsied during proctoscopy. RESULTS The mean (± standard deviation) age of the respondents was 62 ± 9.61 years. The prevalence of a positive FIT in the study was 10.1%. The FIT was not completed by 3.8% of patients, and the rate of completion of additional evaluation after a positive FIT reduced as the investigations became invasive, with 36.8% and 71.1% noncompletion rates for proctoscopy and colonoscopy, respectively. CONCLUSION A FIT-based screening for age and risk-appropriate patients is practical in this environment, where the capacity and acceptability of colonoscopy are limited.
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Affiliation(s)
- Elizabeth O Labaeka
- Department of Family Medicine University, College Hospital Ibadan, Ibadan, Nigeria
| | - Achiaka E Irabor
- Department of Family Medicine University, College Hospital Ibadan, Ibadan, Nigeria
| | - David O Irabor
- Department of Surgery, Division of Gastrointestinal Surgery, University College Hospital Ibadan, Ibadan, Nigeria
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Gluskin AB, Dueker JM, Khalid A. High Rate of Inappropriate Fecal Immunochemical Testing at a Large Veterans Affairs Health Care System. Fed Pract 2021; 38:270-275. [PMID: 34733074 PMCID: PMC8560050 DOI: 10.12788/fp.0142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Colonoscopies and fecal immunochemical tests (FITs) are the preferred modalities for colorectal cancer (CRC) screening. In addition to proper patient selection, appropriate fecal immunochemical testing requires that negative tests be repeated annually, positive tests lead to a diagnostic colonoscopy, and FIT not be performed within 5 years of a colonoscopy with adequate bowel preparation. We sought to study the frequency of inappropriate FITs at the Veterans Affairs Pittsburgh Health Care System in Pennsylvania. METHODS A retrospective quality assurance study was undertaken of veterans undergoing FIT in a 3-year period (2015-2017). We calculated the rate of a negative initial FIT in 2015/2016 followed by a second FIT in 2016/2017 in a random selection of veterans (3% SE, 95% CI). Demographics were compared in an equal random number of veterans that did and did not have a follow-up FIT (5% SE, 95% CI of all negative FIT). We also calculated the rate of completing colonoscopy following a positive FIT in a random selection of veterans (3% SE, 95% CI). Finally, we investigated use of FIT following a colonoscopy for all veterans in the study period. RESULTS A total of 6,766 FITs were performed; 4,391 unique veterans had at least 1 negative FIT, and 709 unique veterans had a positive FIT. Of 1,742 veterans with at least 1 negative FIT, 870 were eligible for repeat testing during the study period, and only 543 (62.4%) underwent at least 2 FITs. There was no significant demographic difference in veterans that had only 1 or at least 2 FITs. Of 410 veterans with a positive FIT, 113 (27.5%) did not undergo a subsequent colonoscopy within 1 year due to patient refusal, or failure to schedule or keep a colonoscopy appointment. Of 832 veterans who had both a FIT and colonoscopy in the interval, 108 veterans underwent colonoscopy with a subsequent FIT (1.6% of total FITs performed). Of these, 95 (88%) were judged to be inappropriate. Thirteen instances of FIT following colonoscopy were appropriate based on patient preference to undergo fecal immunochemical testing for CRC screening modality after undergoing colonoscopy with an inadequate bowel preparation. CONCLUSIONS Veterans underwent inappropriate testing due to failure to undergo serial FIT after a negative result (37.6%), failure to complete colonoscopy following a positive FIT (27.5%), and undergoing inappropriate FIT following a recent colonoscopy (88%). Efforts are still required to improve both patient and provider education and adherence to appropriate fecal immunochemical testing and CRC screening guidelines.
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Affiliation(s)
- Adam B Gluskin
- is a Gastroenterology Fellow and and are Gastroenterologists at Veterans Affairs Pittsburgh Health Care System and the University of Pittsburgh Medical Center in Pennsylvania
| | - Jeffrey M Dueker
- is a Gastroenterology Fellow and and are Gastroenterologists at Veterans Affairs Pittsburgh Health Care System and the University of Pittsburgh Medical Center in Pennsylvania
| | - Asif Khalid
- is a Gastroenterology Fellow and and are Gastroenterologists at Veterans Affairs Pittsburgh Health Care System and the University of Pittsburgh Medical Center in Pennsylvania
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San Miguel Y, Demb J, Martinez ME, Gupta S, May FP. Time to Colonoscopy After Abnormal Stool-Based Screening and Risk for Colorectal Cancer Incidence and Mortality. Gastroenterology 2021; 160:1997-2005.e3. [PMID: 33545140 PMCID: PMC8096663 DOI: 10.1053/j.gastro.2021.01.219] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 01/18/2021] [Accepted: 01/23/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND AND AIMS The optimal time interval for diagnostic colonoscopy completion after an abnormal stool-based colorectal cancer (CRC) screening test is uncertain. We examined the association between time to colonoscopy and CRC outcomes among individuals who underwent diagnostic colonoscopy after abnormal stool-based screening. METHODS We performed a retrospective cohort study of veterans age 50 to 75 years with an abnormal fecal occult blood test (FOBT) or fecal immunochemical test (FIT) between 1999 and 2010. We used multivariable Cox proportional hazards to generate CRC-specific incidence and mortality hazard ratios (HRs) and 95% confidence intervals (CI) for 3-month colonoscopy intervals, with 1 to 3 months as the reference group. Association of time to colonoscopy with late-stage CRC diagnosis was also examined. RESULTS Our cohort included 204,733 patients. Mean age was 61 years (SD 6.9). Compared with patients who received a colonoscopy at 1 to 3 months, there was an increased CRC risk for patients who received a colonoscopy at 13 to 15 months (HR 1.13; 95% CI 1.00-1.27), 16 to 18 months (HR 1.25; 95% CI 1.10-1.43), 19 to 21 months (HR 1.28; 95% CI: 1.11-1.48), and 22 to 24 months (HR 1.26; 95% CI 1.07-1.47). Compared with patients who received a colonoscopy at 1 to 3 months, mortality risk was higher in groups who received a colonoscopy at 19 to 21 months (HR 1.52; 95% CI 1.51-1.99) and 22 to 24 months (HR 1.39; 95% CI 1.03-1.88). Odds for late-stage CRC increased at 16 months. CONCLUSIONS Increased time to colonoscopy is associated with higher risk of CRC incidence, death, and late-stage CRC after abnormal FIT/FOBT. Interventions to improve CRC outcomes should emphasize diagnostic follow-up within 1 year of an abnormal FIT/FOBT result.
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Affiliation(s)
- Yazmin San Miguel
- Division of Gastroenterology, Department of Medicine, Veterans Affairs San Diego Healthcare System, San Diego, California; Moores Cancer Center and Department of Family Medicine and Public Health, University of California San Diego, La Jolla, California
| | - Joshua Demb
- Division of Gastroenterology, Department of Internal Medicine, University of California San Diego, La Jolla, California
| | - Maria Elena Martinez
- Moores Cancer Center and Department of Family Medicine and Public Health, University of California San Diego, La Jolla, California
| | - Samir Gupta
- Division of Gastroenterology, Department of Medicine, Veterans Affairs San Diego Healthcare System, San Diego, California; Division of Gastroenterology, Department of Internal Medicine, University of California San Diego, La Jolla, California.
| | - Folasade P May
- Division of Gastroenterology, Department of Medicine, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California; Vatche and Tamar Manoukian Division of Digestive Diseases and Jonsson Comprehensive Cancer Center, David Geffen School of Medicine, University of California, Los Angeles, California.
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Forbes N, Hilsden RJ, Martel M, Ruan Y, Dube C, Rostom A, Shorr R, Menard C, Brenner DR, Barkun AN, Heitman SJ. Association Between Time to Colonoscopy After Positive Fecal Testing and Colorectal Cancer Outcomes: A Systematic Review. Clin Gastroenterol Hepatol 2020; 19:1344-1354.e8. [PMID: 33010414 PMCID: PMC7527352 DOI: 10.1016/j.cgh.2020.09.048] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 09/14/2020] [Accepted: 09/20/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIMS Colonoscopy is required following a positive fecal screening test for colorectal cancer (CRC). It remains unclear to what extent time to colonoscopy is associated with CRC-related outcomes. We performed a systematic review to elucidate this relationship. METHODS An electronic search was performed through April 2020 for studies reporting associations between time from positive fecal testing to colonoscopy and outcomes including CRC incidence (primary outcome), CRC stage at diagnosis, and/or CRC-specific mortality. Our primary objective was to quantify these relationships following positive fecal immunochemical testing (FIT). Two authors independently performed screening, abstraction, and risk of bias assessments. RESULTS From 1,612 initial studies, 8 were included in the systematic review, with 5 reporting outcomes for FIT. Although meta-analysis was not possible, consistent trends between longer time delays and worse outcomes were apparent in all studies. Colonoscopy performed beyond 9 months from positive FIT compared to within 1 month was significantly associated with a higher incidence of CRC, with adjusted odds ratios (AORs) of 1.75 and 1.48 in the two largest studies. These studies also reported significant associations between colonoscopy performed beyond 9 months and higher incidence of advanced stage CRC (stage III or IV) at diagnosis, with AORs of 2.79 and 1.55, respectively. CONCLUSIONS Colonoscopy for positive FIT should not be delayed beyond 9 months. Given the additional time required for urgent referrals and surgical planning for CRC, colonoscopy should ideally be performed well in advance of 9 months following a positive FIT.
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Affiliation(s)
- Nauzer Forbes
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Cancer Epidemiology and Prevention Research, Cancer Care Alberta, Alberta Health Services, Calgary, Alberta, Canada
| | - Robert J Hilsden
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Cancer Epidemiology and Prevention Research, Cancer Care Alberta, Alberta Health Services, Calgary, Alberta, Canada
| | - Myriam Martel
- Division of Gastroenterology and Hepatology, McGill University Health Centre, McGill University, Montreal, Quebec, Canada
| | - Yibing Ruan
- Department of Cancer Epidemiology and Prevention Research, Cancer Care Alberta, Alberta Health Services, Calgary, Alberta, Canada
| | - Catherine Dube
- Division of Gastroenterology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Alaa Rostom
- Division of Gastroenterology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Risa Shorr
- Learning Services, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Charles Menard
- Division of Gastroenterology and Hepatology, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Darren R Brenner
- Department of Oncology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Cancer Epidemiology and Prevention Research, CancerControl Alberta, Alberta Health Services, Calgary, Alberta, Canada
| | - Alan N Barkun
- Division of Gastroenterology and Hepatology, McGill University Health Centre, McGill University, Montreal, Quebec, Canada
| | - Steven J Heitman
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Cancer Epidemiology and Prevention Research, Cancer Care Alberta, Alberta Health Services, Calgary, Alberta, Canada.
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Paltiel O, Keidar Tirosh A, Paz Stostky O, Calderon-Margalit R, Cohen AD, Elran E, Valinsky L, Matz E, Krieger M, Yehuda AB, Jaffe DH, Manor O. Adherence to national guidelines for colorectal cancer screening in Israel: Comprehensive multi-year assessment based on electronic medical records. J Med Screen 2020; 28:25-33. [PMID: 32356670 DOI: 10.1177/0969141320919152] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVES To assess time trends in colorectal cancer screening uptake, time-to-colonoscopy completion following a positive fecal occult blood test and associated patient factors, and the extent and predictors of longitudinal screening adherence in Israel. SETTING Nation-wide population-based study using data collected from four health maintenance organizations for the Quality Indicators in Community Healthcare Program. METHODS Screening uptake for the eligible population (aged 50-74) was recorded 2003-2018 using aggregate data. For a subcohort (2008-2012, N = 1,342,617), time-to-colonoscopy following a positive fecal occult blood test and longitudinal adherence to screening guidelines were measured using individual-level data, and associated factors assessed in multivariate models. RESULTS The annual proportion screened rose for both sexes from 11 to 65%, increasing five-fold for age group 60-74 and >six-fold for 50-59 year olds, respectively. From 2008 to 2012, 67,314 adults had a positive fecal occult blood test, of whom 71% eventually performed a colonoscopy after a median interval of 122 (95% confidence interval 110.2-113.7) days. Factors associated with time-to-colonoscopy included age, socioeconomic status, and comorbidities. Only 25.5% of the population demonstrated full longitudinal screening adherence, mainly attributable to colonoscopy in the past 10 years rather than annual fecal occult blood test performance (83% versus 17%, respectively). Smoking, diabetes, lower socioeconomic status, cardiovascular disease, and hypertension were associated with decreased adherence. Performance of other cancer screening tests and frequent primary care visits were strongly associated with adherence. CONCLUSIONS Despite substantial improvement in colorectal cancer screening uptake on a population level, individual-level data uncovered gaps in colonoscopy completion after a positive fecal occult blood test and in longitudinal adherence to screening, which should be addressed using focused interventions.
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Affiliation(s)
- Ora Paltiel
- Braun School of Public Health and Community Medicine, Hadassah-Hebrew University, Jerusalem, Israel.,Quality Indicators in Community Healthcare Program, Jerusalem, Israel
| | - Aravah Keidar Tirosh
- Braun School of Public Health and Community Medicine, Hadassah-Hebrew University, Jerusalem, Israel.,Quality Indicators in Community Healthcare Program, Jerusalem, Israel
| | - Orit Paz Stostky
- Pharmacy Department, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
| | - Ronit Calderon-Margalit
- Braun School of Public Health and Community Medicine, Hadassah-Hebrew University, Jerusalem, Israel.,Quality Indicators in Community Healthcare Program, Jerusalem, Israel
| | - Arnon D Cohen
- Department of Quality Measurements and Research, Chief Physician's Office, Clalit Health Services, Tel Aviv, Israel
| | - Einat Elran
- Quality Management Department, Maccabi Healthcare Services, Tel Aviv, Israel
| | - Liora Valinsky
- Quality Department, Meuhedet Health Care, Tel Aviv, Israel
| | - Eran Matz
- Community Health Services, Leumit Health Services, Tel Aviv, Israel
| | - Michal Krieger
- Quality Indicators in Community Healthcare Program, Jerusalem, Israel
| | - Arye Ben Yehuda
- Quality Indicators in Community Healthcare Program, Jerusalem, Israel.,Department of Internal Medicine, Hadassah-Hebrew University, Jerusalem, Israel
| | - Dena H Jaffe
- Braun School of Public Health and Community Medicine, Hadassah-Hebrew University, Jerusalem, Israel.,Quality Indicators in Community Healthcare Program, Jerusalem, Israel
| | - Orly Manor
- Braun School of Public Health and Community Medicine, Hadassah-Hebrew University, Jerusalem, Israel.,Quality Indicators in Community Healthcare Program, Jerusalem, Israel
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Cusumano VT, Corona E, Partida D, Yang L, Yu C, May FP. Patients without colonoscopic follow-up after abnormal fecal immunochemical tests are often unaware of the abnormal result and report several barriers to colonoscopy. BMC Gastroenterol 2020; 20:115. [PMID: 32306919 PMCID: PMC7168865 DOI: 10.1186/s12876-020-01262-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Accepted: 04/03/2020] [Indexed: 02/08/2023] Open
Abstract
Background The fecal immunochemical test (FIT) is the second most commonly used colorectal cancer (CRC) screening modality in the United States; yet, follow-up of abnormal FIT results with diagnostic colonoscopy is underutilized. Our objective was to determine patient-reported barriers to diagnostic colonoscopy following abnormal FIT in an academic healthcare setting. Methods We included patients age 50–75 with an abnormal FIT result between 1/1/2015 and 10/31/2017 and no documented follow-up diagnostic colonoscopy. We abstracted demographic data from the electronic health record (EHR). Study personnel conducted telephone surveys with patients to confirm colonoscopy completion and elicit data on notification of FIT results and barriers to colonoscopy. We also provided brief verbal education about diagnostic colonoscopy. We calculated frequencies of demographic data and survey responses and compared survey responses by interest in colonoscopy after education. Results We surveyed 67 patients. Fifty-one were aware of the abnormal FIT result, and a majority learned of the abnormal FIT result by direct communication with providers (19, 37.3%) or EHR messaging (11, 21.6%). Overall, fifty-three patients (79.1%) confirmed lack of colonoscopy, citing provider-related (19, 35.8%), patient-related (16, 30.2%), system-related (1, 1.9%), or multifactorial (17, 32.1%) reasons. Lack of knowledge of FIT result (14, 26.4%) was most common. After brief education, 20 (37.7%) patients requested colonoscopy. Conclusion Patients with an abnormal FIT reported various multi-level barriers to diagnostic colonoscopy after abnormal FIT, including knowledge of FIT results. When provided with brief education, participants expressed interest in diagnostic colonoscopy. Future efforts will evaluate interventions to improve colonoscopy follow-up.
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Affiliation(s)
- Vivy T Cusumano
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Edgar Corona
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, USA.,Vatche and Tamar Manoukian Division of Digestive Diseases, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Diana Partida
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Liu Yang
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, USA.,Vatche and Tamar Manoukian Division of Digestive Diseases, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Christine Yu
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, USA.,Department of Gastroenterology, Southern California Permanente Medical Group, Los Angeles, California, USA
| | - Folasade P May
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, USA. .,Vatche and Tamar Manoukian Division of Digestive Diseases, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, USA. .,UCLA Kaiser Permanente Center for Health Equity, Jonsson Comprehensive Cancer Center, Los Angeles, California, USA. .,Department of Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA.
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8
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Clarke L, Pockney P, Gillies D, Foster R, Gani J. Time to colonoscopy for patients accessing the direct access colonoscopy service compared to the normal service in Newcastle, Australia. Intern Med J 2020; 49:1132-1137. [PMID: 30411454 DOI: 10.1111/imj.14157] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2018] [Revised: 10/27/2018] [Accepted: 10/30/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND The 2017 National Bowel Cancer Screening Program report records a median time from positive faecal occult blood test to colonoscopy of 53 days. There is some intrinsic delay in accessing specialist medical opinion prior to colonoscopy. AIM To examine the effect of the introduction of a Direct Access Colonoscopy Service (DACS). METHODS Using prospectively maintained databases, patients undergoing normal service (NS) colonoscopy and those referred to DACS were compared. The primary outcome measure was the time from general practitioner (GP) referral to colonoscopy. Secondary outcome measures included the proportion of patients who met the current recommended 30 days from GP referral to colonoscopy, and the proportion of patients who waited longer than 90 days. RESULTS There were 289 patients in the NS group, and 601 patients who progressed on the DACS pathway. The demographics of both groups were comparable. DACS patients had a median waiting time of 49 days, significantly shorter than NS patients whose median wait was 79 days (P < 0.0001). Approximately 15.1% patients in the DACS group had their colonoscopy within 30 days from GP referral, significantly better than in the NS group (4.5%, P < 0.001). In the NS group, 41.2% patients waited longer than 90 days from GP referral to colonoscopy, compared with 16.3% in the DACS group (P < 0.001). CONCLUSION DACS reduces waiting times to colonoscopy and is associated with an increased proportion of patients undergoing colonoscopy in a timely manner.
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Affiliation(s)
- Louise Clarke
- John Hunter Hospital, Newcastle, New South Wales, Australia
| | - Peter Pockney
- John Hunter Hospital, Newcastle, New South Wales, Australia.,University of Newcastle, Newcastle, New South Wales, Australia
| | - Donna Gillies
- John Hunter Hospital, Newcastle, New South Wales, Australia.,Hunter New England Cancer Network Directorate, Newcastle, New South Wales, Australia
| | - Robert Foster
- John Hunter Hospital, Newcastle, New South Wales, Australia
| | - Jon Gani
- John Hunter Hospital, Newcastle, New South Wales, Australia.,University of Newcastle, Newcastle, New South Wales, Australia
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Min JK, Cha JM, Kwak MS, Yoon JY, Jung Y, Shin JE, Yang HJ. Quality Indicators and Outcome Measures of Endoscopy in the National Cancer Screening Program. Yonsei Med J 2019; 60:1054-1060. [PMID: 31637887 PMCID: PMC6813148 DOI: 10.3349/ymj.2019.60.11.1054] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Revised: 08/09/2019] [Accepted: 08/19/2019] [Indexed: 12/28/2022] Open
Abstract
PURPOSE Quality indicators of the National Endoscopy Quality Improvement Program (NEQIP) and outcome measures of endoscopy in the National Cancer Screening Program (NCSP) in Korea are not clear. We evaluated the quality indicators of the revised NEQIP and outcome measures of endoscopy at different types of healthcare facilities participating in the NCSP. MATERIALS AND METHODS This study was conducted between March and August 2018 in primary, secondary, and tertiary healthcare facilities that perform endoscopy as a part of the NCSP. Representative endoscopists completed a questionnaire for quality indicators of the NEQIP and provided data on outcome measures for endoscopy. RESULTS Quality indicators of the NEQIP were mostly acceptable. However, the quality indicators for annual volume of esophagogastroduodenoscopy (EGD) and colonoscopy, training for endoscopy quality improvement by endoscopy nursing staff, colonoscopy reports, documentation of pathologic lesions, quality of endoscopy reprocessing areas, and completion of endoscopy reprocessing education programs were suboptimal. For outcome measures of EGD, the number of photo-documentations and total procedure time were higher at tertiary healthcare facilities than at other facilities (p<0.001 and p=0.023, respectively). For the outcome measures of colonoscopy, colonoscopy completion rate and waiting times for colonoscopy were significantly higher at tertiary healthcare facilities than at other facilities (both p<0.001). CONCLUSION Outcome measures of endoscopy should be included as quality indicators of NCSP. However, universal outcome measures for all types of healthcare facilities should be established because performance levels of some outcome measures differ among individual healthcare facility types.
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Affiliation(s)
- Jun Ki Min
- Department of Internal Medicine, Kyung Hee University Hospital at Gangdong, Seoul, Korea
| | - Jae Myung Cha
- Department of Internal Medicine, Kyung Hee University Hospital at Gangdong, Seoul, Korea
- Department of Internal Medicine, Kyung Hee University School of Medicine, Seoul, Korea.
| | - Min Seob Kwak
- Department of Internal Medicine, Kyung Hee University Hospital at Gangdong, Seoul, Korea
- Department of Internal Medicine, Kyung Hee University School of Medicine, Seoul, Korea
| | - Jin Young Yoon
- Department of Internal Medicine, Kyung Hee University Hospital at Gangdong, Seoul, Korea
- Department of Internal Medicine, Kyung Hee University School of Medicine, Seoul, Korea
| | - Yunho Jung
- Department of Internal Medicine, Soonchunhyang University College of Medicine, Cheonan, Korea
| | - Jeong Eun Shin
- Department of Internal Medicine, Dankook University College of Medicine, Cheonan, Korea
| | - Hyo Joon Yang
- Department of Internal Medicine and Gastrointestinal Cancer Center, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
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10
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Kaalby L, Rasmussen M, Zimmermann-Nielsen E, Buijs MM, Baatrup G. Time to colonoscopy, cancer probability, and precursor lesions in the Danish colorectal cancer screening program. Clin Epidemiol 2019; 11:659-667. [PMID: 31440102 PMCID: PMC6679696 DOI: 10.2147/clep.s206873] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Accepted: 06/03/2019] [Indexed: 12/14/2022] Open
Abstract
Purpose The aim of this study was to investigate the effect of response time from the Fecal Immunochemical Test (FIT) based screening invitation to the conclusive screening Optical Colonoscopy (OC) on the risk of detecting colorectal cancer (CRC), advanced stage disease and precursor lesions. Patients and methods We used a cross-sectional study design and included all 62,554 screening participants registered in the Danish Colorectal Cancer Screening Database who tested FIT-positive between March 2014 and December 2016. The main exposure was response time, measured as the time from initial invitation to the conclusive OC. Our main outcomes were the probability of being diagnosed with CRC, advanced stage disease or precursor lesions. Results Of the 62,554 FIT-positive participants, 53,171 (85%) received an OC and were eligible for analysis (median age 63.7 years, 56% men). In this group, 3,639 cancers were registered, 2,890 of which were registered with a defined stage of disease (79%), and 1,042 (36%) of these were advanced stage (UICC III & IV). In addition, 17,732 high-risk and 10,605 low-risk adenomas were identified. Compared to participants receiving the conclusive examination within 30 days, those receiving the examination more than 90 days after initial invitation were 3.49 times more likely to be diagnosed with any CRC (OR 3.49 [95% CI, 3.13–3.89]) and 2.10 times more likely to have advanced stage disease (OR 2.10 [95% CI, 1.73–2.56]). Those waiting for the longest were also more likely to have one or more high-risk adenomas (OR 1.59 [95% CI, 1.50–1.68]). Conclusion Increased screening response time was associated with a higher probability of detecting high-risk adenomas, any stage CRC and advanced stage cancer. More research is needed to explain what causes these associations.
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Affiliation(s)
- Lasse Kaalby
- Department of Surgery, Odense University Hospital, Odense, Denmark.,Department of Clinical Science, University of Southern Denmark, Odense, Denmark
| | - Morten Rasmussen
- Department of Digestive Diseases K, Bispebjerg Hospital, Copenhagen, Denmark
| | | | | | - Gunnar Baatrup
- Department of Surgery, Odense University Hospital, Odense, Denmark.,Department of Clinical Science, University of Southern Denmark, Odense, Denmark
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11
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Beshara A, Ahoroni M, Comanester D, Vilkin A, Boltin D, Dotan I, Niv Y, Cohen AD, Levi Z. Association between time to colonoscopy after a positive guaiac fecal test result and risk of colorectal cancer and advanced stage disease at diagnosis. Int J Cancer 2019; 146:1532-1540. [DOI: 10.1002/ijc.32497] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Accepted: 05/09/2019] [Indexed: 12/22/2022]
Affiliation(s)
- Amani Beshara
- Division of GastroenterologyRabin Medical Center Petah Tikva Israel
- Sackler School of Medicine, Tel Aviv University Tel Aviv Israel
| | - Maya Ahoroni
- Division of GastroenterologyRabin Medical Center Petah Tikva Israel
| | | | - Alex Vilkin
- Division of GastroenterologyRabin Medical Center Petah Tikva Israel
| | - Doron Boltin
- Division of GastroenterologyRabin Medical Center Petah Tikva Israel
- Sackler School of Medicine, Tel Aviv University Tel Aviv Israel
| | - Iris Dotan
- Division of GastroenterologyRabin Medical Center Petah Tikva Israel
- Sackler School of Medicine, Tel Aviv University Tel Aviv Israel
| | - Yaron Niv
- Division of GastroenterologyRabin Medical Center Petah Tikva Israel
- Sackler School of Medicine, Tel Aviv University Tel Aviv Israel
| | - Arnon D. Cohen
- Department of Quality Measurements and ResearchChief Physician's Office, Clalit Health Services Tel Aviv Israel
- Siaal Research Center for Family Medicine and Primary Care, Faculty of Health SciencesBen‐Gurion University of the Negev Beer‐Sheva Israel
| | - Zohar Levi
- Division of GastroenterologyRabin Medical Center Petah Tikva Israel
- Sackler School of Medicine, Tel Aviv University Tel Aviv Israel
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12
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Breen N, Skinner CS, Zheng Y, Inrig S, Corley DA, Beaber EF, Garcia M, Chubak J, Doubeni C, Quinn VP, Haas JS, Li CI, Wernli KJ, Klabunde CN. Time to Follow-up After Colorectal Cancer Screening by Health Insurance Type. Am J Prev Med 2019; 56:e143-e152. [PMID: 31003603 PMCID: PMC6820676 DOI: 10.1016/j.amepre.2019.01.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2018] [Revised: 01/03/2019] [Accepted: 01/04/2019] [Indexed: 01/28/2023]
Abstract
INTRODUCTION The purpose of this study was to test the hypothesis that patients with Medicaid insurance or Medicaid-like coverage would have longer times to follow-up and be less likely to complete colonoscopy compared with patients with commercial insurance within the same healthcare systems. METHODS A total of 35,009 patients aged 50-64years with a positive fecal immunochemical test were evaluated in Northern and Southern California Kaiser Permanente systems and in a North Texas safety-net system between 2011 and 2012. Kaplan-Meier estimation was used between 2016 and 2017 to calculate the probability of having follow-up colonoscopy by coverage type. Among Kaiser Permanente patients, Cox regression was used to estimate hazard ratios and 95% CIs for the association between coverage type and receipt of follow-up, adjusting for sociodemographics and health status. RESULTS Even within the same integrated system with organized follow-up, patients with Medicaid were 24% less likely to complete follow-up as those with commercial insurance. Percentage receiving colonoscopy within 3 months after a positive fecal immunochemical test was 74.6% for commercial insurance, 63.10% for Medicaid only, and 37.5% for patients served by the integrated safety-net system. CONCLUSIONS This study found that patients with Medicaid were less likely than those with commercial insurance to complete follow-up colonoscopy after a positive fecal immunochemical test and had longer average times to follow-up. With the future of coverage mechanisms uncertain, it is important and timely to assess influences of health insurance coverage on likelihood of follow-up colonoscopy and identify potential disparities in screening completion.
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Affiliation(s)
- Nancy Breen
- Office of Science Planning, Policy, Analysis, Reporting and Data, National Institute on Minority Health and Health Disparities, NIH, Bethesda, Maryland.
| | - Celette Sugg Skinner
- Department of Clinical Sciences, Parkland Health and Hospital System/University of Texas Southwestern Medical Center, Dallas, Texas; Department of Population Sciences, Simmons Comprehensive Cancer Center, Dallas, Texas
| | - Yingye Zheng
- Department of Biostatistics, Public Health Science Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Stephen Inrig
- Department of Clinical Sciences, Parkland Health and Hospital System/University of Texas Southwestern Medical Center, Dallas, Texas
| | - Douglas A Corley
- Division of Research, Kaiser Permanente San Francisco Medical Center, San Francisco, California
| | - Elisabeth F Beaber
- Department of Biostatistics, Public Health Science Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Mike Garcia
- Department of Biostatistics, Public Health Science Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Jessica Chubak
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
| | - Chyke Doubeni
- Department of Family Medicine and Community Health, Perelman School of Medicine, Universityof Pennsylvania, Philadelphia, Pennsylvania
| | - Virginia P Quinn
- Research and Evaluation, Kaiser Permanente Southern California, Los Angeles, California
| | - Jennifer S Haas
- Brigham and Women's Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Christopher I Li
- Department of Biostatistics, Public Health Science Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Karen J Wernli
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
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13
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Association of time to colonoscopy after a positive fecal test result and fecal hemoglobin concentration with risk of advanced colorectal neoplasia. Dig Liver Dis 2019; 51:589-594. [PMID: 30733186 DOI: 10.1016/j.dld.2018.12.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Revised: 12/10/2018] [Accepted: 12/11/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND We evaluated the risk of advanced colorectal neoplasia (ACRN) and colorectal cancer (CRC) according to time to colonoscopy after positive fecal immunochemical test (FIT), fecal hemoglobin concentration, and combination of both. METHODS We analyzed the records of 2362 patients aged ≥50 years who underwent colonoscopy because of a positive FIT result through the National Cancer Screening Program of Korea. RESULTS ACRN risk increased with increasing time to colonoscopy after a positive FIT (17.2%, 18.6%, 19.1%, 21.4%, and 27.2% in <30, 30-59, 60-149, 150-179, and ≥180 days; P = 0.034), and ACRN and CRC risk increased with increasing fecal hemoglobin concentration (ACRN, 13.2%, 16.9%, 18.5%, 23.2%, and 26.6%; CRC, 1.3%, 1.7%, 4.7%, 5.7%, and 12.8% with 100-200, 200-300, 300-500, 500-1000, and ≥1000 ng Hb/mL; both P < 0.001). Even after adjusting for confounders, follow-up after 180 days tended to be associated with a higher ACRN risk (adjusted odds ratio, 1.73; 95% confidence interval [CI], 0.91-3.27), compared with follow-up colonoscopy at <30 days, and fecal hemoglobin 500-1000, and ≥1000 ng Hb/mL were associated with a significantly higher ACRN and CRC risk, compared with 100-200 ng Hb/mL. Moreover, the group with ≥180 days and ≥1000 ng Hb/mL had a much higher CRC risk compared with the group with <180 days and <1000 ng Hb/mL (12.45-fold; 95% CI, 3.73-41.57). CONCLUSIONS Patients with positive FIT results, especially those with higher fecal hemoglobin levels, should undergo timely follow-up colonoscopy.
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14
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Azulay R, Valinsky L, Hershkowitz F, Magnezi R. Repeated Automated Mobile Text Messaging Reminders for Follow-Up of Positive Fecal Occult Blood Tests: Randomized Controlled Trial. JMIR Mhealth Uhealth 2019; 7:e11114. [PMID: 30720439 PMCID: PMC6379817 DOI: 10.2196/11114] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Revised: 08/25/2018] [Accepted: 10/26/2018] [Indexed: 01/09/2023] Open
Abstract
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)
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Affiliation(s)
- Revital Azulay
- Master of Health Administration Program, Department of Management, Bar Ilan University, Ramat Gan, Israel.,Central Laboratory, Meuhedet Health Care, Lod, Israel
| | - Liora Valinsky
- Quality Department, Meuhedet Health Care, Tel Aviv, Israel
| | | | - Racheli Magnezi
- Master of Health Administration Program, Department of Management, Bar Ilan University, Ramat Gan, Israel
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15
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Kim DH, Cha JM, Kwak MS, Yoon JY, Cho YH, Jeon JW, Shin HP, Joo KR, Lee JI. Quality Metrics of a Fecal Immunochemical Test-Based Colorectal Cancer Screening Program in Korea. Gut Liver 2018; 12:183-189. [PMID: 29212310 PMCID: PMC5832343 DOI: 10.5009/gnl17030] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2017] [Revised: 05/01/2017] [Accepted: 06/19/2017] [Indexed: 12/12/2022] Open
Abstract
Background/Aims Knowledge regarding the quality metrics of fecal immunochemical test (FIT)-based colorectal cancer screening programs is limited. The aim of this study was to investigate the performance and quality metrics of a FIT-based screening program. Methods In our screening program, asymptomatic subjects aged ≥50 years underwent an annual FIT, and subjects with positive FIT results underwent a subsequent colonoscopy. The performance of the FIT and colonoscopy was analyzed in individuals with a positive FIT who completed the program between 2009 and 2015 at a university hospital. Results Among the 51,439 screened participants, 75.1% completed the FIT. The positive rate was 1.1%, and the colonoscopy completion rate in these patients was 68.6%. The positive predictive values of cancer and advanced neoplasia were 5.5% and 19.1%, respectively. The adenoma detection rate in the patients who underwent colonoscopy after a positive FIT was 48.2% (60.0% for men and 33.6% for women). The group with the highest tertile quantitative FIT level showed a significantly higher detection rate of advanced neoplasia than the group with the lowest tertile (odds ratio, 2.6; 95% confidence interval, 1.4 to 5.1; p<0.001). Conclusions The quality metrics used in the United States and Europe may be directly introduced to other countries, including Korea. However, the optimal quality metrics should be established in each country.
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Affiliation(s)
- Dae Ho Kim
- Department of Medicine, Graduate School, Kyung Hee University, Seoul, Korea
| | - Jae Myung Cha
- Department of Internal Medicine, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, Seoul, Korea
| | - Min Seob Kwak
- Department of Internal Medicine, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, Seoul, Korea
| | - Jin Young Yoon
- Department of Medicine, Graduate School, Kyung Hee University, Seoul, Korea.,Department of Internal Medicine, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, Seoul, Korea
| | - Young-Hak Cho
- Department of Internal Medicine, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, Seoul, Korea
| | - Jung Won Jeon
- Department of Internal Medicine, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, Seoul, Korea
| | - Hyun Phil Shin
- Department of Internal Medicine, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, Seoul, Korea
| | - Kwang Ro Joo
- Department of Internal Medicine, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, Seoul, Korea
| | - Joung Il Lee
- Department of Internal Medicine, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, Seoul, Korea
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16
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Doubeni CA, Gabler NB, Wheeler CM, McCarthy AM, Castle PE, Halm EA, Schnall MD, Skinner CS, Tosteson ANA, Weaver DL, Vachani A, Mehta SJ, Rendle KA, Fedewa SA, Corley DA, Armstrong K. Timely follow-up of positive cancer screening results: A systematic review and recommendations from the PROSPR Consortium. CA Cancer J Clin 2018; 68:199-216. [PMID: 29603147 PMCID: PMC5980732 DOI: 10.3322/caac.21452] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Revised: 02/09/2018] [Accepted: 02/21/2018] [Indexed: 12/19/2022] Open
Abstract
Timely follow-up for positive cancer screening results remains suboptimal, and the evidence base to inform decisions on optimizing the timeliness of diagnostic testing is unclear. This systematic review evaluated published studies regarding time to follow-up after a positive screening for breast, cervical, colorectal, and lung cancers. The quality of available evidence was very low or low across cancers, with potential attenuated or reversed associations from confounding by indication in most studies. Overall, evidence suggested that the risk for poorer cancer outcomes rises with longer wait times that vary within and across cancer types, which supports performing diagnostic testing as soon as feasible after the positive result, but evidence for specific time targets is limited. Within these limitations, we provide our opinion on cancer-specific recommendations for times to follow-up and how existing guidelines relate to the current evidence. Thresholds set should consider patient worry, potential for loss to follow-up with prolonged wait times, and available resources. Research is needed to better guide the timeliness of diagnostic follow-up, including considerations for patient preferences and existing barriers, while addressing methodological weaknesses. Research is also needed to identify effective interventions for reducing wait times for diagnostic testing, particularly in underserved or low-resource settings. CA Cancer J Clin 2018;68:199-216. © 2018 American Cancer Society.
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Affiliation(s)
- Chyke A. Doubeni
- Department of Family Medicine and Community Health, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Nicole B. Gabler
- Department of Family Medicine and Community Health, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Cosette M. Wheeler
- Departments of Pathology, and Obstetrics and Gynecology, University of New Mexico Health Science Center, Albuquerque, NM
| | - Anne Marie McCarthy
- General Medicine Division, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Philip E. Castle
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY
| | - Ethan A. Halm
- Departments of Internal Medicine and Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, TX
| | - Mitchell D. Schnall
- Department of Radiology, Breast Imaging Section, University of Pennsylvania, Perelman School of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Celette S. Skinner
- Department of Clinical Sciences and Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, TX
| | - Anna N. A. Tosteson
- The Dartmouth Institute for Health Policy and Clinical Practice and Norris Cotton Cancer Center, Geisel School of Medicine at Dartmouth, Lebanon, NH
| | - Donald L. Weaver
- Department of Pathology, UVM Cancer Center, University of Vermont, Burlington, VT
| | - Anil Vachani
- Pulmonary, Allergy, and Critical Care Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Shivan J. Mehta
- Department of Medicine, Perelman School of Medicine and Penn Center for Health Care Innovation, University of Pennsylvania, Philadelphia, PA
| | - Katharine A. Rendle
- Department of Family Medicine and Community Health, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Stacey A Fedewa
- Surveillance and Health Services Research, American Cancer Society. Atlanta, GA
| | - Douglas A. Corley
- Kaiser Permanente Division of Research, Oakland, CA, and San Francisco Medical, Kaiser Permanente Northern California, San Francisco, CA
| | - Katrina Armstrong
- General Medicine Division, Massachusetts General Hospital, Harvard Medical School, Boston, MA
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17
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Thamarasseril S, Bhuket T, Chan C, Liu B, Wong RJ. The Need for an Integrated Patient Navigation Pathway to Improve Access to Colonoscopy After Positive Fecal Immunochemical Testing: A Safety-Net Hospital Experience. J Community Health 2018; 42:551-557. [PMID: 27796633 DOI: 10.1007/s10900-016-0287-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Colorectal cancer (CRC) is a leading cause of cancer-related deaths in the United States. Delays in access to colonoscopy following positive fecal immunochemical test (FIT) contribute to increased CRC incidence and mortality. To evaluate intervals from positive FIT result to receipt of colonoscopy among underserved safety-net populations. We retrospectively evaluated all average CRC risk adults who had positive FIT results from 2012 to 2015 at an ethnically diverse safety-net hospital system. Interval from positive FIT to receipt of colonoscopy was evaluated with Kaplan Meier methods and multivariate Cox proportional hazards models. Among 467 patients with positive FIT (48.4 % men, 39.5 % black, 22.5 % white, 17.4 % Asian, 9.7 % Hispanic, mean age 59.5 ± 9.8 years), mean time from positive FIT to receipt of colonoscopy was 220.5 days (SD 158.5). Compared to men, there was a trend towards longer time from FIT positive to colonoscopy among women (237.1 vs. 198.7 days, p = 0.07). No race/ethnicity-specific disparities in time to colonoscopy were observed. Compared to 2012-2013, there was a 27.2 % reduction in time from FIT positive to colonoscopy in 2014-2015 (173.9 vs. 238.8 days, p < 0.01). Among patients undergoing colonoscopy, 46.3 % had adenomatous polyps, 27.4 % had high risk adenomatous polyps, and 5.6 % had CRC. Among an ethnically diverse safety-net hospital system, improvements in access to colonoscopy after positive FIT were observed. However, patients still waited nearly 6 months from time of positive FIT to undergoing colonoscopy. Delays in receipt of colonoscopy are complex and reflect system-level and individual patient-level barriers.
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Affiliation(s)
- Sreedevi Thamarasseril
- Department of Medicine, Division of Gastroenterology and Hepatology, Alameda Health System - Highland Hospital, 1411 East 31st Street, Highland Hospital - Highland Care Pavilion 5th Floor, Oakland, CA, 94602, USA
| | - Taft Bhuket
- Department of Medicine, Division of Gastroenterology and Hepatology, Alameda Health System - Highland Hospital, 1411 East 31st Street, Highland Hospital - Highland Care Pavilion 5th Floor, Oakland, CA, 94602, USA
| | - Chuck Chan
- Department of Medicine, Division of Gastroenterology and Hepatology, Alameda Health System - Highland Hospital, 1411 East 31st Street, Highland Hospital - Highland Care Pavilion 5th Floor, Oakland, CA, 94602, USA
| | - Benny Liu
- Department of Medicine, Division of Gastroenterology and Hepatology, Alameda Health System - Highland Hospital, 1411 East 31st Street, Highland Hospital - Highland Care Pavilion 5th Floor, Oakland, CA, 94602, USA
| | - Robert J Wong
- Department of Medicine, Division of Gastroenterology and Hepatology, Alameda Health System - Highland Hospital, 1411 East 31st Street, Highland Hospital - Highland Care Pavilion 5th Floor, Oakland, CA, 94602, USA.
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18
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Selby K, Baumgartner C, Levin TR, Doubeni CA, Zauber AG, Schottinger J, Jensen CD, Lee JK, Corley DA. Interventions to Improve Follow-up of Positive Results on Fecal Blood Tests: A Systematic Review. Ann Intern Med 2017; 167:565-575. [PMID: 29049756 PMCID: PMC6178946 DOI: 10.7326/m17-1361] [Citation(s) in RCA: 86] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Fecal immunochemical testing is the most commonly used method for colorectal cancer screening worldwide. However, its effectiveness is frequently undermined by failure to obtain follow-up colonoscopy after positive test results. PURPOSE To evaluate interventions to improve rates of follow-up colonoscopy for adults after a positive result on a fecal test (guaiac or immunochemical). DATA SOURCES English-language studies from the Cochrane Central Register of Controlled Trials, PubMed, and Embase from database inception through June 2017. STUDY SELECTION Randomized and nonrandomized studies reporting an intervention for colonoscopy follow-up of asymptomatic adults with positive fecal test results. DATA EXTRACTION Two reviewers independently extracted data and ranked study quality; 2 rated overall strength of evidence for each category of study type. DATA SYNTHESIS Twenty-three studies were eligible for analysis, including 7 randomized and 16 nonrandomized studies. Three were at low risk of bias. Eleven studies described patient-level interventions (changes to invitation, provision of results or follow-up appointments, and patient navigators), 5 provider-level interventions (reminders or performance data), and 7 system-level interventions (automated referral, precolonoscopy telephone calls, patient registries, and quality improvement efforts). Moderate evidence supported patient navigators and provider reminders or performance data. Evidence for system-level interventions was low. Seventeen studies reported the proportion of test-positive patients who completed colonoscopy compared with a control population, with absolute differences of -7.4 percentage points (95% CI, -19 to 4.3 percentage points) to 25 percentage points (CI, 14 to 35 percentage points). LIMITATION More than half of studies were at high or very high risk of bias; heterogeneous study designs and characteristics precluded meta-analysis. CONCLUSION Patient navigators and giving providers reminders or performance data may help improve colonoscopy rates of asymptomatic adults with positive fecal blood test results. Current evidence about useful system-level interventions is scant and insufficient. PRIMARY FUNDING SOURCE National Cancer Institute. (PROSPERO: CRD42016048286).
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Affiliation(s)
- Kevin Selby
- From Kaiser Permanente Division of Research, Oakland, California; University of Lausanne, Lausanne, Switzerland; University of California at San Francisco, San Francisco, California; Bern University Hospital, Bern, Switzerland; Kaiser Permanente Medical Center, Walnut Creek, California; University of Pennsylvania, Philadelphia, Pennsylvania; Memorial Sloan Kettering Cancer Center, New York, New York; and Kaiser Permanente, Pasadena, California
| | - Christine Baumgartner
- From Kaiser Permanente Division of Research, Oakland, California; University of Lausanne, Lausanne, Switzerland; University of California at San Francisco, San Francisco, California; Bern University Hospital, Bern, Switzerland; Kaiser Permanente Medical Center, Walnut Creek, California; University of Pennsylvania, Philadelphia, Pennsylvania; Memorial Sloan Kettering Cancer Center, New York, New York; and Kaiser Permanente, Pasadena, California
| | - Theodore R Levin
- From Kaiser Permanente Division of Research, Oakland, California; University of Lausanne, Lausanne, Switzerland; University of California at San Francisco, San Francisco, California; Bern University Hospital, Bern, Switzerland; Kaiser Permanente Medical Center, Walnut Creek, California; University of Pennsylvania, Philadelphia, Pennsylvania; Memorial Sloan Kettering Cancer Center, New York, New York; and Kaiser Permanente, Pasadena, California
| | - Chyke A Doubeni
- From Kaiser Permanente Division of Research, Oakland, California; University of Lausanne, Lausanne, Switzerland; University of California at San Francisco, San Francisco, California; Bern University Hospital, Bern, Switzerland; Kaiser Permanente Medical Center, Walnut Creek, California; University of Pennsylvania, Philadelphia, Pennsylvania; Memorial Sloan Kettering Cancer Center, New York, New York; and Kaiser Permanente, Pasadena, California
| | - Ann G Zauber
- From Kaiser Permanente Division of Research, Oakland, California; University of Lausanne, Lausanne, Switzerland; University of California at San Francisco, San Francisco, California; Bern University Hospital, Bern, Switzerland; Kaiser Permanente Medical Center, Walnut Creek, California; University of Pennsylvania, Philadelphia, Pennsylvania; Memorial Sloan Kettering Cancer Center, New York, New York; and Kaiser Permanente, Pasadena, California
| | - Joanne Schottinger
- From Kaiser Permanente Division of Research, Oakland, California; University of Lausanne, Lausanne, Switzerland; University of California at San Francisco, San Francisco, California; Bern University Hospital, Bern, Switzerland; Kaiser Permanente Medical Center, Walnut Creek, California; University of Pennsylvania, Philadelphia, Pennsylvania; Memorial Sloan Kettering Cancer Center, New York, New York; and Kaiser Permanente, Pasadena, California
| | - Christopher D Jensen
- From Kaiser Permanente Division of Research, Oakland, California; University of Lausanne, Lausanne, Switzerland; University of California at San Francisco, San Francisco, California; Bern University Hospital, Bern, Switzerland; Kaiser Permanente Medical Center, Walnut Creek, California; University of Pennsylvania, Philadelphia, Pennsylvania; Memorial Sloan Kettering Cancer Center, New York, New York; and Kaiser Permanente, Pasadena, California
| | - Jeffrey K Lee
- From Kaiser Permanente Division of Research, Oakland, California; University of Lausanne, Lausanne, Switzerland; University of California at San Francisco, San Francisco, California; Bern University Hospital, Bern, Switzerland; Kaiser Permanente Medical Center, Walnut Creek, California; University of Pennsylvania, Philadelphia, Pennsylvania; Memorial Sloan Kettering Cancer Center, New York, New York; and Kaiser Permanente, Pasadena, California
| | - Douglas A Corley
- From Kaiser Permanente Division of Research, Oakland, California; University of Lausanne, Lausanne, Switzerland; University of California at San Francisco, San Francisco, California; Bern University Hospital, Bern, Switzerland; Kaiser Permanente Medical Center, Walnut Creek, California; University of Pennsylvania, Philadelphia, Pennsylvania; Memorial Sloan Kettering Cancer Center, New York, New York; and Kaiser Permanente, Pasadena, California
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Fundamental causes of accelerated declines in colorectal cancer mortality: Modeling multiple ways that disadvantage influences mortality risk. Soc Sci Med 2017. [PMID: 28645039 DOI: 10.1016/j.socscimed.2017.06.013] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Improvements in colorectal cancer (CRC) mortality reflect the distribution of effective preventions. Social inequalities often generate unequal diffusion of medical interventions, resulting in disparate outcomes while preventions are being disseminated throughout the population. This study used a novel method to examine whether Race (Black versus White) and SES influenced when rates of CRC mortality started to decline, and how rapidly they did so. METHOD Mortality counts from 1968-2010 were derived from death certificates of U.S. residents aged 25 + years. Individuals' race, age, county of residence, and sex were collected from death certificates. County-level SES was measured using the decennial U.S. census. Layered joinpoint regression was used to model CRC mortality trends over time. Acceleration in rates of historical decline were used to indicate preventability within counties. RESULTS Black race was associated with a 4.1-year delay in colonoscopy-attributable declines in CRC mortality and each standard deviation unit change in SES with a 5.7-year delay in such mortality. Following the onset of a decline, colonoscopy-attributable mortality change was slower by 0.5% among Blacks, and 2.0%/standard deviation in SES. Modifying the rapidity of colonoscopy uptake could have averted 12-14,000 and 83-86,000 deaths among Blacks and residents of lower SES counties, respectively. CONCLUSIONS Successful interventions do not uniformly benefit the U.S. POPULATION This study highlighted the notable impact that substantial delays in the provision of interventions, and in the relative rapidity of dissemination, and estimated the extent to which there was a preventable loss of life concentrated amongst the most disadvantaged. A more egalitarian delivery of life-saving interventions could drastically reduce mortality by improving effectiveness of interventions while also addressing inequalities in health.
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Corley DA, Jensen CD, Quinn VP, Doubeni CA, Zauber AG, Lee JK, Schottinger JE, Marks AR, Zhao WK, Ghai NR, Lee AT, Contreras R, Quesenberry CP, Fireman BH, Levin TR. Association Between Time to Colonoscopy After a Positive Fecal Test Result and Risk of Colorectal Cancer and Cancer Stage at Diagnosis. JAMA 2017; 317:1631-1641. [PMID: 28444278 PMCID: PMC6343838 DOI: 10.1001/jama.2017.3634] [Citation(s) in RCA: 189] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
IMPORTANCE The fecal immunochemical test (FIT) is commonly used for colorectal cancer screening and positive test results require follow-up colonoscopy. However, follow-up intervals vary, which may result in neoplastic progression. OBJECTIVE To evaluate time to colonoscopy after a positive FIT result and its association with risk of colorectal cancer and advanced-stage disease at diagnosis. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study (January 1, 2010-December 31, 2014) within Kaiser Permanente Northern and Southern California. Participants were 70 124 patients aged 50 through 70 years eligible for colorectal cancer screening with a positive FIT result who had a follow-up colonoscopy. EXPOSURES Time (days) to colonoscopy after a positive FIT result. MAIN OUTCOMES AND MEASURES Risk of any colorectal cancer and advanced-stage disease (defined as stage III and IV cancer). Odds ratios (ORs) and 95% CIs were adjusted for patient demographics and baseline risk factors. RESULTS Of the 70 124 patients with positive FIT results (median age, 61 years [IQR, 55-67 years]; men, 52.7%), there were 2191 cases of any colorectal cancer and 601 cases of advanced-stage disease diagnosed. Compared with colonoscopy follow-up within 8 to 30 days (n = 27 176), there were no significant differences between follow-up at 2 months (n = 24 644), 3 months (n = 8666), 4 to 6 months (n = 5251), or 7 to 9 months (n = 1335) for risk of any colorectal cancer (cases per 1000 patients: 8-30 days, 30; 2 months, 28; 3 months, 31; 4-6 months, 31; and 7-9 months, 43) or advanced-stage disease (cases per 1000 patients: 8-30 days, 8; 2 months, 7; 3 months, 7; 4-6 months, 9; and 7-9 months, 13). Risks were significantly higher for examinations at 10 to 12 months (n = 748) for any colorectal cancer (OR, 1.48 [95% CI, 1.05-2.08]; 49 cases per 1000 patients) and advanced-stage disease (OR, 1.97 [95% CI, 1.14-3.42]; 19 cases per 1000 patients) and more than 12 months (n = 747) for any colorectal cancer (OR, 2.25 [95% CI, 1.89-2.68]; 76 cases per 1000 patients) and advanced-stage disease (OR, 3.22 [95% CI, 2.44-4.25]; 31 cases per 1000 patients). CONCLUSIONS AND RELEVANCE Among patients with a positive fecal immunochemical test result, compared with follow-up colonoscopy at 8 to 30 days, follow-up after 10 months was associated with a higher risk of colorectal cancer and more advanced-stage disease at the time of diagnosis. Further research is needed to assess whether this relationship is causal.
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Affiliation(s)
- Douglas A. Corley
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | | | - Virginia P. Quinn
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - Chyke A. Doubeni
- Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Ann G. Zauber
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Jeffrey K. Lee
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Joanne E. Schottinger
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - Amy R. Marks
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Wei K. Zhao
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Nirupa R. Ghai
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - Alexander T. Lee
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - Richard Contreras
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | | | - Bruce H. Fireman
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Theodore R. Levin
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
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Dalton ARH. Incomplete diagnostic follow-up after a positive colorectal cancer screening test: a systematic review. J Public Health (Oxf) 2017; 40:e46-e58. [DOI: 10.1093/pubmed/fdw147] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Accepted: 12/20/2016] [Indexed: 12/19/2022] Open
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Chubak J, Garcia MP, Burnett-Hartman AN, Zheng Y, Corley DA, Halm EA, Singal AG, Klabunde CN, Doubeni CA, Kamineni A, Levin TR, Schottinger JE, Green BB, Quinn VP, Rutter CM. Time to Colonoscopy after Positive Fecal Blood Test in Four U.S. Health Care Systems. Cancer Epidemiol Biomarkers Prev 2016; 25:344-50. [PMID: 26843520 DOI: 10.1158/1055-9965.epi-15-0470] [Citation(s) in RCA: 91] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND To reduce colorectal cancer mortality, positive fecal blood tests must be followed by colonoscopy. METHODS We identified 62,384 individuals ages 50 to 89 years with a positive fecal blood test between January 1, 2011 and December 31, 2012 in four health care systems within the Population-Based Research Optimizing Screening through Personalized Regimens (PROSPR) consortium. We estimated the probability of follow-up colonoscopy and 95% confidence intervals (CI) using the Kaplan-Meier method. Overall differences in cumulative incidence of follow-up across health care systems were assessed with the log-rank test. HRs and 95% CIs were estimated from multivariate Cox proportional hazards models. RESULTS Most patients who received a colonoscopy did so within 6 months of their positive fecal blood test, although follow-up rates varied across health care systems (P <0.001). Median days to colonoscopy ranged from 41 (95% CI, 40-41) to 174 (95% CI, 123-343); percent followed-up by 12 months ranged from 58.1% (95% CI, 51.6%-63.7%) to 83.8% (95% CI, 83.4%-84.3%) and differences across health care systems were also observed at 1, 2, 3, and 6 months. Increasing age and comorbidity score were associated with lower follow-up rates. CONCLUSION Individual characteristics and health care system were associated with colonoscopy after positive fecal blood tests. Patterns were consistent across health care systems, but proportions of patients receiving follow-up varied. These findings suggest that there is room to improve follow-up of positive colorectal cancer screening tests. IMPACT Understanding the timing of colonoscopy after positive fecal blood tests and characteristics associated with lack of follow-up may inform future efforts to improve follow-up.
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Affiliation(s)
| | | | - Andrea N Burnett-Hartman
- Fred Hutchinson Cancer Research Center, Seattle, Washington. Institute for Health Research, Kaiser Permanente Colorado, Denver, Colorado
| | - Yingye Zheng
- Fred Hutchinson Cancer Research Center, Seattle, Washington
| | | | - Ethan A Halm
- Departments of Internal Medicine and Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Amit G Singal
- Departments of Internal Medicine and Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, Texas
| | | | - Chyke A Doubeni
- Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Meester RG, Zauber AG, Doubeni CA, Jensen CD, Quinn VP, Helfand M, Dominitz JA, Levin TR, Corley DA, Lansdorp-Vogelaar I. Consequences of Increasing Time to Colonoscopy Examination After Positive Result From Fecal Colorectal Cancer Screening Test. Clin Gastroenterol Hepatol 2016; 14:1445-1451.e8. [PMID: 27211498 PMCID: PMC5028249 DOI: 10.1016/j.cgh.2016.05.017] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Revised: 04/15/2016] [Accepted: 05/02/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS Delays in diagnostic testing after a positive result from a screening test can undermine the benefits of colorectal cancer (CRC) screening, but there are few empirical data on the effects of such delays. We used microsimulation modeling to estimate the consequences of time to colonoscopy after a positive result from a fecal immunochemical test (FIT). METHODS We used an established microsimulation model to simulate an average-risk United States population cohort that underwent annual FIT screening (from ages 50 to 75 years), with follow-up colonoscopy examinations for individuals with positive results (cutoff, 20 μg/g) at different time points in the following 12 months. Main evaluated outcomes were CRC incidence and mortality; additional outcomes were total life-years lost and net costs of screening. RESULTS For individuals who underwent diagnostic colonoscopy within 2 weeks of a positive result from an FIT, the estimated lifetime risk of CRC incidence was 35.5/1000 persons, and mortality was 7.8/1000 persons. Every month added until colonoscopy was associated with a 0.1/1000 person increase in cancer incidence risk (an increase of 0.3%/month, compared with individuals who received colonoscopies within 2 weeks) and mortality risk (increase of 1.4%/month). Among individuals who received colonoscopy examinations 12 months after a positive result from an FIT, the incidence of CRC was 37.0/1000 persons (increase of 4%, compared with 2 weeks), and mortality was 9.1/1000 persons (increase of 16%). Total years of life gained for the entire screening cohort decreased from an estimated 93.7/1000 persons with an almost immediate follow-up colonoscopy (cost savings of $208 per patient, compared with no colonoscopy) to 84.8/1000 persons with follow-up colonoscopies at 12 months (decrease of 9%; cost savings of $100/patient, compared with no colonoscopy). CONCLUSIONS By using a microsimulation model of an average-risk United States screening cohort, we estimated that delays of up to 12 months after a positive result from an FIT can produce proportional losses of up to nearly 10% in overall screening benefits. These findings indicate the importance of timely follow-up colonoscopy examinations of patients with positive results from FITs.
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Affiliation(s)
- Reinier G.S. Meester
- Department of Public Health, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Ann G. Zauber
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Chyke A. Doubeni
- Department of Family Medicine and Community Health in the Perelman School of Medicine, Department of Epidemiology in the Perelman School of Medicine, and the Leonard Davis Institute of Health Economics and Center for Public Health Initiatives, University of Pennsylvania, Philadelphia, PA, United States
| | | | - Virginia P. Quinn
- Kaiser Permanente Southern California, Research & Evaluation, Pasadena, CA, United States
| | - Mark Helfand
- Veterans Affairs Portland Healthcare System, Portland, OR, United States
| | - Jason A. Dominitz
- Veterans Affairs Puget Sound Healthcare System, Seattle, WA, United States,Division of Gastroenterology, University of Washington School of Medicine, Seattle, Washington, USA
| | | | | | - Iris Lansdorp-Vogelaar
- Department of Public Health, Erasmus MC University Medical Center, Rotterdam, Netherlands
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Partin MR, Gravely A, Gellad ZF, Nugent S, Burgess JF, Shaukat A, Nelson DB. Factors Associated With Missed and Cancelled Colonoscopy Appointments at Veterans Health Administration Facilities. Clin Gastroenterol Hepatol 2016; 14:259-67. [PMID: 26305071 DOI: 10.1016/j.cgh.2015.07.051] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2015] [Revised: 07/16/2015] [Accepted: 07/18/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Cancelled and missed colonoscopy appointments waste resources, increase colonoscopy delays, and can adversely affect patient outcomes. We examined individual and organizational factors associated with missed and cancelled colonoscopy appointments in Veteran Health Administration facilities. METHODS From 69 facilities meeting inclusion criteria, we identified 27,994 patients with colonoscopy appointments scheduled for follow-up, on the basis of positive fecal occult blood test results, between August 16, 2009 and September 30, 2011. We identified factors associated with colonoscopy appointment status (completed, cancelled, or missed) by using hierarchical multinomial regression. Individual factors examined included age, race, sex, marital status, residence, drive time to nearest specialty care facility, limited life expectancy, comorbidities, colonoscopy in the past decade, referring facility type, referral month, and appointment lead time. Organizational factors included facility region, complexity, appointment reminders, scheduling, and prep education practices. RESULTS Missed appointments were associated with limited life expectancy (odds ratio [OR], 2.74; P = .0004), no personal history of polyps (OR, 2.74; P < .0001), high facility complexity (OR, 2.69; P = .007), dual diagnosis of psychiatric disorders and substance abuse (OR, 1.82; P < .0001), and opt-out scheduling (OR, 1.57; P = .02). Cancelled appointments were associated with age (OR, 1.61; P = .0005 for 85 years or older and OR, 1.44; P < .0001 for 65-84 years old), no history of polyps (OR, 1.51; P < .0001), and opt-out scheduling (OR, 1.26; P = .04). Additional predictors of both outcomes included race, marital status, and lead time. CONCLUSIONS Several factors within Veterans Health Administration clinic control can be targeted to reduce missed and cancelled colonoscopy appointments. Specifically, developing systems to minimize referrals for patients with limited life expectancy could reduce missed appointments, and use of opt-in scheduling and reductions in appointment lead time could improve both outcomes.
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Affiliation(s)
- Melissa R Partin
- Center for Chronic Disease Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota; Department of Medicine, University of Minnesota, Minneapolis, Minnesota.
| | - Amy Gravely
- Center for Chronic Disease Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota
| | - Ziad F Gellad
- Durham Veterans Affairs Health Care System, Durham, North Carolina; Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Sean Nugent
- Center for Chronic Disease Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota
| | - James F Burgess
- Center for Healthcare Organization and Implementation Research, Boston Veterans Affairs Health Care System, Boston, Massachusetts; Department of Health Policy and Management, Boston University School of Public Health, Boston, Massachusetts
| | - Aasma Shaukat
- Center for Chronic Disease Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota; Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - David B Nelson
- Center for Chronic Disease Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota; Department of Medicine, University of Minnesota, Minneapolis, Minnesota
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Correia A, Rabeneck L, Baxter NN, Paszat LF, Sutradhar R, Yun L, Tinmouth J. Lack of follow-up colonoscopy after positive FOBT in an organized colorectal cancer screening program is associated with modifiable health care practices. Prev Med 2015; 76:115-22. [PMID: 25895843 DOI: 10.1016/j.ypmed.2015.03.028] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2014] [Revised: 03/16/2015] [Accepted: 03/21/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND ColonCancerCheck (CCC), Ontario's organized colorectal cancer (CRC) screening program, uses guaiac fecal occult blood testing (gFOBT). To reduce CRC-related mortality, persons with a positive gFOBT must have colonoscopy. We identified factors associated with failure to have colonoscopy within 6months of a positive gFOBT. METHODS Population-based, retrospective cohort analysis of CCC participants with positive gFOBT (April 2008 to December 2009) using health administrative data. Patient, physician and health care utilization factors associated with a lack of follow-up colonoscopy were identified using descriptive and multivariate analyses. RESULTS There were 21,839 participants with a positive gFOBT; 14,091 (64%) had colonoscopy within 6months. The strongest factors associated with failure to follow-up were recent colonoscopy (in 2years prior vs. >10years or never, OR: 4.31, 95% C.I.: 3.82, 4.86), as well as repeat gFOBT (OR: 6.08, 95% C.I.: 5.46, 6.78) and hospital admission (OR: 4.35, 95% C.I.: 3.57, 5.26) in the follow-up period. CONCLUSION In the first 18months of the CCC Program, 1/3 of those with a positive gFOBT did not have colonoscopy within 6months. Identification of potentially modifiable factors associated with failure to follow up lay the groundwork for interventions to address this critical quality gap.
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Affiliation(s)
- Adriano Correia
- Credit Valley Hospital, Trillium Health Partners, Mississauga, Ontario, Canada.
| | - Linda Rabeneck
- Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada; Institute for Clinical Evaluative Sciences, Toronto, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada; Cancer Care Ontario, Toronto, Canada.
| | - Nancy N Baxter
- Institute for Clinical Evaluative Sciences, Toronto, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada; Department of Surgery and Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada; Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada; Department of Surgery, University of Toronto, Toronto, Ontario, Canada.
| | - Lawrence F Paszat
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, Canada; Institute for Clinical Evaluative Sciences, Toronto, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, Canada.
| | - Rinku Sutradhar
- Institute for Clinical Evaluative Sciences, Toronto, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, Canada.
| | - Lingsong Yun
- Institute for Clinical Evaluative Sciences, Toronto, Canada.
| | - Jill Tinmouth
- Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada; Institute for Clinical Evaluative Sciences, Toronto, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada; Cancer Care Ontario, Toronto, Canada; Department of Medicine, University of Toronto, Toronto, Ontario, Canada.
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Partin MR, Burgess DJ, Burgess JF, Gravely A, Haggstrom D, Lillie SE, Nugent S, Powell AA, Shaukat A, Walter LC, Nelson DB. Organizational predictors of colonoscopy follow-up for positive fecal occult blood test results: an observational study. Cancer Epidemiol Biomarkers Prev 2015; 24:422-34. [PMID: 25471345 PMCID: PMC4323731 DOI: 10.1158/1055-9965.epi-14-1170] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND This study assessed the contribution of organizational structures and processes identified from facility surveys to follow-up for positive fecal occult blood tests [FOBT-positive (FOBT(+))]. METHODS We identified 74,104 patients with FOBT(+) results from 98 Veterans Health Administration (VHA) facilities between August 16, 2009 and March 20, 2011, and followed them until September 30, 2011, for completion of colonoscopy. We identified patient characteristics from VHA administrative records, and organizational factors from facility surveys completed by primary care and gastroenterology chiefs. We estimated predictors of colonoscopy completion within 60 days and six months using hierarchical logistic regression models. RESULTS Thirty percent of patients with FOBT(+) results received colonoscopy within 60 days and 49% within six months. Having gastroenterology or laboratory staff notify gastroenterology providers directly about FOBT(+) cases was a significant predictor of 60-day [odds ratio (OR), 1.85; P = 0.01] and six-month follow-up (OR, 1.25; P = 0.008). Additional predictors of 60-day follow-up included adequacy of colonoscopy appointment availability (OR, 1.43; P = 0.01) and frequent individual feedback to primary care providers about FOBT(+) referral timeliness (OR, 1.79; P = 0.04). Additional predictors of six-month follow-up included using guideline-concordant surveillance intervals for low-risk adenomas (OR, 1.57; P = 0.01) and using group appointments and combined verbal-written methods for colonoscopy preparation instruction (OR, 1.48; P = 0.0001). CONCLUSION Directly notifying gastroenterology providers about FOBT(+) results, using guideline-concordant adenoma surveillance intervals, and using colonoscopy preparations instruction methods that provide both verbal and written information may increase overall follow-up rates. Enhancing follow-up within 60 days may require increased colonoscopy capacity and feedback to primary care providers. IMPACT These findings may inform organizational-level interventions to improve FOBT(+) follow-up.
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Affiliation(s)
- Melissa R Partin
- Center for Chronic Disease Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota. Department of Medicine, University of Minnesota, Minneapolis, Minnesota.
| | - Diana J Burgess
- Center for Chronic Disease Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota. Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - James F Burgess
- Center for Healthcare Organization and Implementation Research, Boston Veterans Affairs Health Care System, Boston, Massachusetts. Department of Health Policy and Management, Boston University School of Public Health, Boston, Massachusetts
| | - Amy Gravely
- Center for Chronic Disease Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota
| | - David Haggstrom
- VA Health Services Research and Development Center for Health Information and Communication, Roudebush VAMC, Indianapolis, Indiana. Division of General Internal Medicine and Geriatrics, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Sarah E Lillie
- Center for Chronic Disease Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota. Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Sean Nugent
- Center for Chronic Disease Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota
| | - Adam A Powell
- Center for Chronic Disease Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota
| | - Aasma Shaukat
- Center for Chronic Disease Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota. Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Louise C Walter
- Division of Geriatrics, San Francisco VA Medical Center and University of California, San Francisco, San Francisco, California
| | - David B Nelson
- Center for Chronic Disease Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota. Department of Medicine, University of Minnesota, Minneapolis, Minnesota
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Colorectal cancer screening: factors associated with colonoscopy after a positive faecal occult blood test. Br J Cancer 2013; 109:1437-44. [PMID: 23989948 PMCID: PMC3776987 DOI: 10.1038/bjc.2013.476] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2013] [Revised: 06/10/2013] [Accepted: 07/25/2013] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Contextual socio-economic factors, health-care access, and general practitioner (GP) involvement may influence colonoscopy uptake and its timing after positive faecal occult blood testing (FOBT). Our objectives were to identify predictors of delayed or no colonoscopy and to assess the role for GPs in colonoscopy uptake. METHODS We included all residents of a French district with positive FOBTs (n = 2369) during one of the two screening rounds (2007-2010). Multilevel logistic regression analysis was performed to identify individual and area-level predictors of delayed colonoscopy, no colonoscopy, and no information on colonoscopy. RESULTS A total of 998 (45.2%) individuals underwent early, 989 (44.8%) delayed, and 102 (4.6%) no colonoscopy; no information was available for 119 (5.4%) individuals. Delayed colonoscopy was independently associated with first FOBT (odds ratio, (OR)), 1.61; 95% confidence interval ((95% CI), 1.16-2.25); and no colonoscopy and no information with first FOBT (OR, 2.01; 95% CI, 1.02-3.97), FOBT kit not received from the GP (OR, 2.29; 95% CI, 1.67-3.14), and socio-economically deprived area (OR, 3.17; 95% CI, 1.98-5.08). Colonoscopy uptake varied significantly across GPs (P=0.01). CONCLUSION Socio-economic factors, GP-related factors, and history of previous FOBT influenced colonoscopy uptake after a positive FOBT. Interventions should target GPs and individuals performing their first screening FOBT and/or living in socio-economically deprived areas.
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Bringing an organizational perspective to the optimal number of colorectal cancer screening options debate. J Gen Intern Med 2012; 27:376-80. [PMID: 21915765 PMCID: PMC3286551 DOI: 10.1007/s11606-011-1870-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2011] [Revised: 08/03/2011] [Accepted: 08/29/2011] [Indexed: 12/24/2022]
Abstract
Improving colorectal cancer (CRC) screening rates represents a challenge for primary care providers. Some have argued that offering a choice of CRC screening modes to patients will improve the currently low adherence rates. Others have raised concerns that offering numerous CRC screening options in practice could overwhelm patients and thus dampen enthusiasm for screening. In this article we assemble evidence to critically evaluate the relative merit of these opposing views. We find little evidence to support the hypothesis that the number of options offered will affect adherence (either positively or negatively), or that expanding the modalities offered beyond FOBT and colonoscopy will improve patient satisfaction. Therefore, we assert future decisions about the number of CRC screening modes to offer would more productively be focused on considerations such as what benefit the health-care organization would derive from offering additional modes, and how this change would affect other critical components of a successful screening program such as timely diagnosis. In light of these organizational level considerations, we agree with the assertion made by others that a screening program limited to FOBT and colonoscopy is likely to be ideal in most settings.
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Evaluation of a VHA collaborative to improve follow-up after a positive colorectal cancer screening test. Med Care 2011; 49:897-903. [PMID: 21642875 DOI: 10.1097/mlr.0b013e3182204944] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND In 2005, the Veterans Health Administration initiated a yearlong Colorectal Cancer Care Collaborative (C4) to improve timely follow-up after positive fecal occult blood tests. METHODS Twenty-one facilities formed local quality improvement (QI) teams. Teams received QI training, created process flow maps, implemented process changes, and shared learning through 2 face-to-face meetings, conference calls, and a discussion board. We evaluated pre-post change in the timeliness of follow-up among C4 facilities and 3 control facilities. Outcome measures included the proportion of patients receiving a follow-up colonoscopy within 1 year, the proportion receiving 60-day follow-up (the focus of C4 teams), and average days to colonoscopy. Survey data from C4 team members was analyzed to identify predictors of facility-level improvement. RESULTS Both C4 and control facilities improved on 1-year follow-up (10% and 9% increases, respectively, both P's<0.001). There was a statistically significant increase in the proportion receiving 60-day follow-up among C4 facilities (27% pre-C4 vs. 39% post-C4, P=0.008) but a nonsignificant decrease among control facilities (45% pre-C4 vs. 29% post-C4, P=0.14). Average days to colonoscopy decreased significantly among C4 facilities (129 pre-C4 vs. 103 post-C4, P=0.004) but increased significantly among control facilities (81 pre-C4 vs. 103 post-C4, P=0.04). Teams with the most improvement established clear roles/goals, had previous QI training, made more use of QI tools, and incorporated primary care education into their improvement work. CONCLUSIONS A Veterans Health Administration improvement collaborative modestly decreased time to colonoscopy after a positive colorectal cancer screening test but significant room for improvement remains and benefits of participation were not realized by all facilities.
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Dupont-Lucas C, Dejardin O, Dancourt V, Launay L, Launoy G, Guittet L. Socio-geographical determinants of colonoscopy uptake after faecal occult blood test. Dig Liver Dis 2011; 43:714-20. [PMID: 21530429 DOI: 10.1016/j.dld.2011.03.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2010] [Revised: 02/23/2011] [Accepted: 03/13/2011] [Indexed: 12/11/2022]
Abstract
BACKGROUND Survival from colorectal cancer is poorer in patients of lower socioeconomic level, or living far from the cancer reference centre. AIMS To evaluate the impact of material deprivation and geographical remoteness on the uptake of colonoscopy after a positive screening faecal occult blood test. METHODS Data from two large French average-risk population-based trials comparing two faecal occult blood tests were used. Compliance with colonoscopy after a positive faecal occult blood test was analysed using a logistic model and a Cox model considering time between faecal occult blood test and colonoscopy. Covariates studied were sex, age, distance to nearest gastroenterologist, distance to regional capital, and Townsend's deprivation score. RESULTS Amongst 4320 eligible subjects, 4131 were included. The rate of colonoscopy was 83.8%, within a median time of 66.0 days after faecal occult blood test. Distance to regional capital (p-trend=0.02) and study centre (p<0.0001) were independently associated with colonoscopy uptake. Time from positive faecal occult blood test to colonoscopy, was associated only with distance to the regional capital (p<0.0001, multivariate model stratified on study centre). CONCLUSION Geographical remoteness but not material deprivation was responsible for lower uptake of colonoscopy. Healthcare decision-makers should focus on geographical remoteness to promote equal access to diagnostic procedures in faecal occult blood test colorectal cancer screening programmes.
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Affiliation(s)
- Claire Dupont-Lucas
- INSERM ERI3 Cancers & Populations, Faculté de Médecine, avenue de la Côte de Nacre, Caen, France
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Van Kleek E, Liu S, Conn LM, Hoadley A, Ho SB. Improving the effectiveness of fecal occult blood testing in a primary care clinic by direct colonoscopy referral for positive tests. J Healthc Qual 2011; 32:62-9. [PMID: 20946427 DOI: 10.1111/j.1945-1474.2009.00071.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Fecal occult blood testing (FOBT) is recommended by national guidelines for colorectal cancer (CRC) screening and has been shown to reduce both the incidence and mortality of CRC. FOBT screening is a complex process and little is known concerning the best methods for implementing FOBT screening in primary care clinics. The purpose of this study was to determine if direct gastroenterology (GI) service notification of all positive FOBT results in improved time for provider response and colonoscopy. The secondary aims were to determine to what extent implementation of FOBT screening was appropriate in a large primary care clinic and correlate this with findings from colonoscopy. Data were collected prospectively following implementation of a direct referral strategy and compared with two retrospective time periods during which the ordering practitioners were responsible for follow-up of all positive FOBT. Implementation of immediate GI referral of positive tests eliminated improper and neglected follow-up, and resulted in shorter delays in provider response time and colonoscopy completion. Inappropriate use of FOBT was observed in 49% of patients, indicating that further interventions in primary care clinics to improve the quality of FOBT screening are necessary.
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Fisher DA, Zullig LL, Grambow SC, Abbott DH, Sandler RS, Fletcher RH, El-Serag HB, Provenzale D. Determinants of medical system delay in the diagnosis of colorectal cancer within the Veteran Affairs Health System. Dig Dis Sci 2010; 55:1434-41. [PMID: 20238248 PMCID: PMC2864330 DOI: 10.1007/s10620-010-1174-9] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2009] [Accepted: 02/19/2010] [Indexed: 01/22/2023]
Abstract
BACKGROUND AND AIMS The goals of this study are to evaluate determinants of the time in the medical system until a colorectal cancer diagnosis and to explore characteristics associated with stage at diagnosis. METHODS We examined medical records and survey data for 468 patients with colorectal cancer at 15 Veterans Affairs medical centers. Patients were classified as screen-detected, bleeding-detected, or other (resulting from the evaluation of another medical concern). Patients who presented emergently with obstruction or perforation were excluded. We used Cox proportional hazards models to determine predictors of time in the medical system until diagnosis. Logistic regression models were used to determine predictors of stage at diagnosis. RESULTS We excluded 21 subjects who presented emergently, leaving 447 subjects; the mean age was 67 years and 98% were male, 66% Caucasian, and 43% stage I or II. Diagnosis was by screening for 39%, bleeding symptoms for 27%, and other for 34%. The median times to diagnosis were 73-91 days and were not significantly different by diagnostic category. In the multivariable model for time to diagnosis, older age, having comorbidities, and Atlantic region were associated with a longer time to diagnosis. In the multivariable model for stage-at-diagnosis, only the diagnostic category was associated with stage; the screen-detected category was associated with decreased risk of late-stage cancer. CONCLUSIONS Our results point to several factors associated with a longer time from the initial clinical event until diagnosis. This increased time in the health care system did not clearly translate into more advanced disease at diagnosis.
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Affiliation(s)
- Deborah A. Fisher
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, NC,Division of Gastroenterology, Department of Medicine, Duke University Medical Center, Durham, NC
| | - Leah L. Zullig
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, NC
| | - Steven C. Grambow
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, NC,Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, NC
| | - David H. Abbott
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, NC
| | - Robert S. Sandler
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, NC
| | | | - Hashem B. El-Serag
- Baylor College of Medicine, Department of Medicine, Section of Gastroenterology and Hepatology, Houston, TX
| | - Dawn Provenzale
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, NC,Division of Gastroenterology, Department of Medicine, Duke University Medical Center, Durham, NC
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Fletcher RH. The diagnosis of colorectal cancer in patients with symptoms: finding a needle in a haystack. BMC Med 2009; 7:18. [PMID: 19374737 PMCID: PMC2672954 DOI: 10.1186/1741-7015-7-18] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2009] [Accepted: 04/17/2009] [Indexed: 11/10/2022] Open
Abstract
Patients often see primary care physicians with symptoms that might signal colorectal cancer but are also common in adults without cancer. Physicians and patients must then make a difficult decision about whether and how aggressively to evaluate the symptom. Favoring referral is that missed diagnoses lead to unnecessary testing, prolonged uncertainty, and continuing symptoms; also, the physician will suffer chagrin. It is not clear that diagnostic delay leads to progression to a more advanced stage. Against referral is that proper evaluation includes colonoscopy, with attendant inconvenience, discomfort, cost, and risk. The article by Hamilton et al, published this month in BMC Medicine, provides strong estimates of the predictive value of the various symptoms and signs of colorectal cancer and show how much higher predictive values are with increasing age and male sex. Unfortunately, their results also make clear that most colorectal cancers present with symptoms with low predictive values, < 1.2%. Models that include a set of predictive variables, that is, risk factors, age, sex, screening history, and symptoms, have been developed to guide primary prevention and clinical decision-making and are more powerful than individual symptoms and signs alone. Although screening for colorectal cancer is increasing in many countries, cancers will still be found outside screening programs so primary care physicians will remain at the front line in the difficult task of distinguishing everyday symptoms from life-threatening cancer.
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