Rates of Follow-up Colonoscopy After a Positive Stool-Based Screening Test Result for Colorectal Cancer Among Health Care Organizations in the US, 2017-2020

Abstract

ImportanceNoninvasive stool-based screening tests (SBTs) are effective alternatives to colonoscopy. However, a positive SBT result requires timely follow-up colonoscopy (FU-CY) to complete the colorectal cancer screening paradigm.ObjectivesTo evaluate FU-CY rates after a positive SBT result and to assess the association of the early COVID-19 pandemic with FU-CY rates.Design, Setting, and ParticipantsThis mixed-methods cohort study included retrospective analysis of deidentified administrative claims and electronic health records data between June 1, 2015, and June 30, 2021, from the Optum Labs Data Warehouse and qualitative, semistructured interviews with clinicians from 5 health care organizations (HCOs). The study population included data from average-risk primary care patients aged 50 to 75 years with a positive SBT result between January 1, 2017, and June 30, 2020, at 39 HCOs.Main Outcomes and MeasuresThe primary outcome was the FU-CY rate within 1 year of a positive SBT result according to patient age, sex, race, ethnicity, insurance type, Charlson Comorbidity Index (CCI), and prior SBT use.ResultsThis cohort study included 32 769 individuals (16 929 [51.7%] female; mean [SD] age, 63.1 [7.1] years; 2092 [6.4%] of Black and 28 832 [88.0%] of White race; and 825 [2.5%] of Hispanic ethnicity). The FU-CY rates were 43.3% within 90 days of the positive SBT result, 51.4% within 180 days, and 56.1% within 360 days (n = 32 769). In interviews, clinicians were uniformly surprised by the low FU-CY rates. Rates varied by race, ethnicity, insurance type, presence of comorbidities, and SBT used. In the Cox proportional hazards regression model, the strongest positive association was with multitarget stool DNA use (hazard ratio, 1.63 [95% CI, 1.57-1.68] relative to fecal immunochemical tests; P < .001), and the strongest negative association was with the presence of comorbidities (hazard ratio, 0.64 [95% CI, 0.59-0.71] for a CCI of >4 relative to 0; P < .001). The early COVID-19 pandemic was associated with lower FU-CY rates.Conclusions and RelevanceThis study found that FU-CY rates after a positive SBT result for colorectal cancer screening were low among an average-risk population, with the median HCO achieving a 53.4% FU-CY rate within 1 year. Socioeconomic factors and the COVID-19 pandemic were associated with lower FU-CY rates, presenting opportunities for targeted intervention by clinicians and health care systems.

Multitarget Stool RNA Test for Colorectal Cancer Screening

“…This is in direct contrast to previously conducted clinical trials in which participant recruitment occurred at endoscopy centers for individuals who already had a colonoscopy scheduled . Although remuneration might have played a role in adherence (see eMethods in Supplement 3), high participation was observed relative to other noninvasive testing platforms . Given that noninvasive colorectal cancer screening depends on the completion of colonoscopy for individuals with a positive screening test result, employing colonoscopy navigation methods described in this study could be used to improve colonoscopy compliance after a positive mt-sRNA test result …”

“…7 Although remuneration might have played a role in adherence (see eMethods in Supplement 3), high participation was observed relative to other noninvasive testing platforms. 20,21 Given that noninvasive colorectal cancer screening depends on the completion of colonoscopy for individuals with a positive screening test result, employing colonoscopy navigation methods described in this study could be used to improve colonoscopy compliance after a positive mt-sRNA test result. 22 Colorectal cancer rates are increasing in younger populations, 23 resulting in the recent recommendation to reduce the screening age from 50 to 45 years.…”

American Cancer Society’s report on the status of cancer disparities in the United States, 2023

“…Differences in stage at diagnosis comprise a major contributing factor to disparities in cancer survival and mortality. 58 screening tests [60][61][62] and receipt of surveillance testing or screening for other cancers among cancer survivors. [63][64][65] Disparities in access to care for following suspicious symptoms can also result in disparities in stage at diagnosis of cancers for which routine screening is not recommended.…”

“…In 2021, for example, the prevalence of being up to date with colorectal cancer screening ranged from 58.2% among individuals without a high school diploma to 77.5% among individuals with a college degree; by race/ethnicity, the prevalence was 73.8% among White people but ranged from 60.2% to 71.7% in other racial/ethnic groups 18 . There are also disparities by race/ethnicity, SES, and provider type in follow‐up of abnormal cancer screening tests 60–62 and receipt of surveillance testing or screening for other cancers among cancer survivors 63–65 . Disparities in access to care for following suspicious symptoms can also result in disparities in stage at diagnosis of cancers for which routine screening is not recommended 66 …”

Development of a Follow-Up Measure to Ensure Complete Screening for Colorectal Cancer

“…[16][17][18][19] In a study using the Optum Labs Data Warehouse (OLDW), follow-up rates at 3 and 6 months were low, at 43% and 51%, respectively. 20 Some health systems have been able to achieve effective follow-up of 85% of patients within 6 months, 21 but substantial variation exists. 20 Quality measures can lead to improved performance, [22][23][24][25][26][27] but the current CRC screening Healthcare Effectiveness Data and Information Set (HEDIS) measure 28 is incomplete for individuals receiving SBTs for screening.…”