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Shareef F, Bharti B, Garcia-Bigley F, Hernandez M, Nodora J, Liu J, Ramers C, Nery JD, Marquez J, Moyano K, Rojas S, Arredondo E, Gupta S. Abnormal Colorectal Cancer Test Follow-Up: A Quality Improvement Initiative at a Federally Qualified Health Center. J Prim Care Community Health 2024; 15:21501319241242571. [PMID: 38554066 PMCID: PMC10981848 DOI: 10.1177/21501319241242571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Revised: 03/07/2024] [Accepted: 03/08/2024] [Indexed: 04/01/2024] Open
Abstract
INTRODUCTION/OBJECTIVES Colonoscopy completion rates after an abnormal fecal immunochemical test (FIT) are suboptimal, resulting in missed opportunities for early detection and prevention of colorectal cancer. Patient navigation and structured follow-up may improve colonoscopy completion, but implementation of these strategies is not widespread. METHODS We conducted a quality improvement study using a Plan-Do-Study-Act (PDSA) Model to increase colonoscopy completion after abnormal FIT in a large federally qualified health center serving a diverse and low-income population. Intervention components included patient navigation, and a checklist to promote completion of key steps required for abnormal FIT follow-up. Primary outcome was proportion of patients achieving colonoscopy completion within 6 months of abnormal FIT, assessed at baseline for 156 patients pre-intervention, and compared to 208 patients during the intervention period from April 2017 to December 2019. Drop offs at each step in the follow-up process were assessed. RESULTS Colonoscopy completion improved from 21% among 156 patients with abnormal FIT pre-intervention, to 38% among 208 patients with abnormal FIT during the intervention (P < .001; absolute increase: 17%, 95% CI: 6.9%-25.2%). Among the 130 non-completers during the intervention period, lack of completion was attributable to absence of colonoscopy referral for 7.7%; inability to schedule a pre-colonoscopy specialist visit for 71.5%; failure to complete a pre-colonoscopy visit for 2.3%; the absence of colonoscopy scheduling for 9.2%; failure to show for a scheduled colonoscopy for 9.2%. CONCLUSIONS Patient navigation and structured follow-up appear to improve colonoscopy completion after abnormal FIT. Additional strategies are needed to achieve optimal rates of completion.
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Affiliation(s)
- Faizah Shareef
- University of California San Diego (Internal Medicine), La Jolla, CA, USA
| | - Balambal Bharti
- University of California San Diego (Internal Medicine), La Jolla, CA, USA
| | | | | | - Jesse Nodora
- University of California San Diego (Radiation Medicine), La Jolla, CA, USA
- Moores Cancer Center, University of California San Diego, La Jolla, CA, USA
| | - Jie Liu
- Shang Consulting LLC, San Diego CA, USA
| | - Christian Ramers
- Family Health Centers of San Diego (Graduate Medical Education), San Diego, CA, USA
| | | | | | - Karina Moyano
- Moores Cancer Center, University of California San Diego, La Jolla, CA, USA
| | | | | | - Samir Gupta
- University of California San Diego (Internal Medicine), La Jolla, CA, USA
- Moores Cancer Center, University of California San Diego, La Jolla, CA, USA
- Veterans Affairs San Diego Healthcare System, San Diego, CA, USA
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Bharti B, May FFP, Nodora J, Martínez ME, Moyano K, Davis SL, Ramers CB, Garcia-Bigley F, O'Connell S, Ronan K, Barajas M, Gordon S, Diaz G, Ceja E, Powers M, Arredondo EM, Gupta S. Diagnostic colonoscopy completion after abnormal fecal immunochemical testing and quality of tests used at 8 Federally Qualified Health Centers in Southern California: Opportunities for improving screening outcomes. Cancer 2019; 125:4203-4209. [PMID: 31479529 DOI: 10.1002/cncr.32440] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Revised: 04/22/2019] [Accepted: 04/24/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND The effectiveness of colorectal cancer screening with fecal immunochemical tests (FITs) of stool blood depends on high rates of colonoscopy follow-up for abnormal FITs and the use of high-quality tests. This study characterized colonoscopy referral and completion among patients with abnormal FITs and the types of FITs implemented in a sample of Southern California Federally Qualified Health Centers (FQHCs). METHODS FQHCs in San Diego, Imperial, and Los Angeles Counties were invited to define a cohort of ≥150 consecutive patients with abnormal FITs in 2015-2016 and to provide data on sex, insurance status, diagnostic colonoscopy referrals and completion within 6 months of abnormal FITs, and the types (brands) of FITs implemented. The primary outcomes were the proportions with colonoscopy referrals and completion for all patients at each FQHC and in aggregate. RESULTS Eight FQHCs provided data for 1229 patients with abnormal FITs; 46% were male, and 20% were uninsured. Among patients with abnormal FITs, 89% (1091 of 1229; 95% confidence interval [CI], 0.87-0.91) had a colonoscopy referral, and 44% (539 of 1229; 95% CI, 0.41-0.47) had colonoscopy completion. Across FQHCs, the range for colonoscopy referral was 73% to 96%, and the range for completion was 18% to 57%. Six of the 8 FQHCs (75%) reported FIT brands with limited data to support their effectiveness. CONCLUSIONS In a sample of Southern California FQHCs, diagnostic colonoscopy completion after abnormal FITs was substantially below the nationally recommended benchmark to achieve 80% completion, and the use of FIT brands with limited data to support their effectiveness was high. These findings suggest a need for policies and multilevel interventions to promote diagnostic colonoscopy among individuals with abnormal FITs and the use of higher quality FITs.
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Affiliation(s)
- Balambal Bharti
- University of California San Diego, La Jolla, California.,Moores Cancer Center, University of California San Diego, La Jolla, California
| | - Folasade Fola Popoola May
- Jonsson Comprehensive Cancer Center and Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California.,Division of Gastroenterology, Department of Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, California
| | - Jesse Nodora
- University of California San Diego, La Jolla, California.,Moores Cancer Center, University of California San Diego, La Jolla, California.,Department of Family Medicine and Public Health, University of California San Diego, La Jolla, California
| | - María Elena Martínez
- University of California San Diego, La Jolla, California.,Moores Cancer Center, University of California San Diego, La Jolla, California.,Department of Family Medicine and Public Health, University of California San Diego, La Jolla, California
| | | | | | - Christian B Ramers
- University of California San Diego, La Jolla, California.,Family Health Centers of San Diego, San Diego, California
| | | | | | | | | | - Sheree Gordon
- To Help Everyone Health and Wellness Centers, Los Angeles, California
| | - Giselle Diaz
- Northeast Valley Health Center, Los Angeles, California
| | - Evelyn Ceja
- South Central Family Health Center, Los Angeles, California
| | | | | | - Samir Gupta
- University of California San Diego, La Jolla, California.,Moores Cancer Center, University of California San Diego, La Jolla, California.,VA San Diego Healthcare System, San Diego, California
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