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

Abstract

Background Delays in receiving follow-up colonoscopy after an abnormal fecal immunochemical test (FIT) result are associated with increased colorectal cancer incidence and mortality. Little is known about patterns of follow-up colonoscopy completion in federally qualified health centers. Methods We abstracted the medical records of health center patients, aged 50–75 years, who had an abnormal FIT result between August 5, 2017 and August 4, 2018 (N = 711). We assessed one-year rates of colonoscopy referral, pre-procedure visit completion, colonoscopy completion, and time to colonoscopy; associations between these outcomes and patient characteristics; and reasons for non-completion found in the medical record. Results Of the 711 patients with an abnormal FIT result, 90% were referred to colonoscopy, but only 52% completed a pre-procedure visit, and 43% completed a colonoscopy within 1 year. Median time to colonoscopy was 83 days (interquartile range: 52–131 days). Pre-procedure visit and colonoscopy completion rates were relatively low in patients aged 65–75 (vs. 50–64), who were uninsured (vs. insured) or had no clinic visit in the prior year (vs. ≥ 1 clinic visit). Common reasons listed for non-completion were that the patient declined, or the provider could not reach the patient. Discussion Efforts to improve follow-up colonoscopy rates in health centers might focus on supporting the care transition from primary to specialty gastroenterology care and emphasize care for older uninsured patients and those having no recent clinic visits. Our findings can inform efforts to improve follow-up colonoscopy uptake, reduce time to colonoscopy receipt, and save lives from colorectal cancer. Trial registration: National Clinical Trial (NCT) Identifier: NCT03925883.

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

“…27,32 Moreover, diverging from the current study where the most common explanation for lack of colonoscopy was system-level factors, earlier reports indicate patient-level factors (declination or appointment no-show 19%-57%) and provider inability to reach patients among the most common reasons for lack of follow-up colonoscopy. 14,27,32,33 Taken together, these findings suggest that FQHC clinical workflows bridging primary care and GI specialists as well as the information technology (IT) infrastructure undergirding them are underdeveloped and fall into a “provider ownership gap.” 14 As 1 possible explanation for this lack of documentation, during the study period, the FQHC migrated to a new EHR, which likely impacted standardized processes regarding abnormal FIT results. The absence of a referral to GI specialist or indication of outcomes following a referral underscores the need to ensure that EHR documentation is routinely taking place and must be given additional consideration through dedicated resources in order to complete the CRC screening continuum.…”

“…These prior reports found 1 year follow-up colonoscopy rates of 18% to 56%. 12,14,16,27,32,33 Patients in these studies, similar to those in the current study, were referred to 1 of several contracted GI specialists complicating successful colonoscopy completion—with the exception of Issaka et al 14 and Martin et al 33 ,where patients were referred to a single network hospital.…”

“…While Issaka et al 14 report 10% of patients completed FIT in error (ie, returned second FIT after the initial 1 with an abnormal result) and FQHCs report 4% of patients given a second FIT, we observed 2% of patients completed a second FIT. 27,32 This overutilization of screening tests in an already strained safety-net system wastes scarce resources and conflicts with medical guidelines, both of which threaten care quality. 37 Integrating prior lab results into panel management and outreach to proactively, accurately screen patients represents 1 EHR strategy to address inappropriate screening and incomplete follow-up.…”

“…We observed 94 days median time from abnormal FIT to follow-up colonoscopy, which was comparable to data in 5 prior reports conducted since 2017 (range: 72-300 days). 14,16,27,32,33 Moreover 14 colonoscopies were completed >12 months. Our observed time to colonoscopy fell just outside the 90 day benchmark set by the PROSPR initiative, suggesting that additional strategies may be needed to support FQHC patients in successfully accessing GI services in a timely manner.…”

“…26 Our team previously reported a chart abstraction-verified 43% follow-up colonoscopy completion rate in a large FQHC headquartered in Seattle. 27 However, data for the analysis did not incorporate Medicaid claims, which represents a reliable source of data on colonoscopy completion. Here, we report chart abstraction-and Medicaid claimsverified data on follow-up colonoscopy receipt from the largest independent FQHC in the US, which serves a patient population that is 83% Latino-44% of which is best served in a language other than English.…”