A Root Cause Analysis of Barriers to Timely Colonoscopy in California Safety-Net Health Systems

Abstract

Objectives: Safety-net health care systems, serving vulnerable populations, see longer delays to timely colonoscopy after a positive fecal occult blood test (FOBT), which may contribute to existing disparities. We sought to identify root causes of colonoscopy delay after positive FOBT result in the primary care safety net. Methods:We conducted a multisite root cause analysis of cases of delayed colonoscopy, identifying cases where there was a delay of greater than 6 months in completing or scheduling a follow-up colonoscopy after a positive FOBT. We identified cases across 5 California health systems serving low-income, vulnerable populations. We developed a semistructured interview guide based on precedent work. We conducted telephone individual interviews with primary care providers (PCPs) and patients. We then performed qualitative content analysis of the interviews, using an integrated inductive-deductive analytic approach, to identify themes related to recurrent root causes of colonoscopy delay. Results:We identified 12 unique cases, comprising 5 patient and 11 PCP interviews. Eight patients completed colonoscopy; median time to colonoscopy was 11.0 months (interquartile range, 6.3 months). Three patients had advanced adenomatous findings. Primary care providers highlighted system-level root causes, including inability to track referrals between primary care and gastroenterology, lack of protocols to follow up with patients, lack of electronic medical record interoperability, and lack of time or staffing resources, compelling tremendous additional effort by staff. In contrast, patients' highlighted individual-level root causes included comorbidities, social needs, and misunderstanding the importance of the FOBT. There was a little overlap between PCP and patient-elicited root causes.Conclusions: Current protocols do not accommodate communication between primary care and gastroenterology. Interventions to address specific barriers identified include improved interoperability between PCP and gastroenterology scheduling systems, protocols to follow-up on incomplete colonoscopies, accommodation for support and transport needs, and patient-friendly education. Interviewing both patients and PCPs leads to richer analysis of the root causes leading to delayed diagnosis of colorectal cancer.

Barriers associated with inadequate follow-up of abnormal fecal immunochemical test results in a safety-net system: A mixed-methods analysis

“…that were not documented in the EHR. These findings are consistent with the limited number of qualitative studies that include safety-net patients ( Jetelina et al, 2019 , Schneider et al, 2020 , Sharma et al, 2020 ). Colonoscopy is a complex process that may be especially challenging for patients in safety-net health systems who experience fragmented care.…”

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

“…However, given the high concordance between EHR-query-obtained and chart-abstracted results (92% for GI referral; 96% for colonoscopy completion), we can be reasonably confident our data include nearly all procedures. Our analysis was also limited to information in the health record, which inherently omits important system-level factors, such as referral tracking procedures, protocols to follow up with patients, health record interoperability, and available staffing resources [ 25 ]. Moreover, reasons for non-completion recorded in the EHR are incomplete and we did not gather qualitative data directly from patients who did not complete the recommended colonoscopy.…”

Perceptions on Barriers and Facilitators to Colonoscopy Completion After Abnormal Fecal Immunochemical Test Results in a Safety Net System

“…10 While 2 studies from 2021 13,14 signaled that patient navigation may be associated with improved colonoscopy completion, qualitative studies of clinician-identified barriers that may inform interventions to further improve follow-up colonoscopy completion are limited. [25][26][27] Through semistructured clinician interviews, our study extends the existing literature by identifying potential areas of intervention within safety net health systems at the patient level (eg, patient transportation), clinician level (eg, patient education), and health system level (eg, primary and specialty care coordination).…”