Timeliness of Colonoscopy After Abnormal Fecal Test Results in a Safety Net Practice

Abstract

Background Fecal testing can only reduce colorectal cancer mortality if patients with an abnormal test result receive a follow-up colonoscopy. As part of the Strategies and Opportunities to STOP Colon Cancer in Priority Populations (STOP CRC) project, we examined factors associated with adherence to follow-up colonoscopy among patients with abnormal fecal test results. Methods As part of STOP CRC outreach, Virginia Garcia Memorial Health Center staff distributed 1,753 fecal immunochemical tests (FIT), of which 677 (39%) were completed, and 56 had an abnormal result (8%). Project staff used logistic regression analyses to examine factors associated with colonoscopy referral and completion. Results Of the 56 patients with abnormal FIT results; 45 (80%) had evidence of a referral for colonoscopy, 32 (57%) had evidence of a completed colonoscopy within 18 months, and 14 (25%) within 60 days of an abnormal fecal test result. In adjusted analysis, Hispanics had lower odds of completing follow-up colonoscopy within 60 days than non-Hispanic whites (adjusted OR = 0.20; 95% CI: 0.04, 0.92). Colonoscopy within 60 days trended lower for women than for men (adjusted OR = 0.25; 95% CI 0.06 – 1.04). Among the 24 patients lacking medical record evidence of a colonoscopy, 19 (79%) had a documented reason, including clinician did not pursue, patient refused, and colonoscopy not indicated. No reason was found for 21%. Conclusion Improvements are needed to increase rates of follow-up colonoscopy completion, especially among female and Hispanic patients.

Contribution of patient, physician, and environmental factors to demographic and health variation in colonoscopy follow‐up for abnormal colorectal cancer screening test results

“…Our observation of the contribution of potentially inappropriate screening because of a recent prior colonoscopy to the follow‐up rate is consistent with findings from prior studies, including 1 that identified recent colonoscopy as a prevalent reason for failure to complete follow‐up and 2 that reported a strong association between colonoscopy history and follow‐up of a positive FOBT/FIT result . Potentially inappropriate screening because of limited life expectancy was relatively rare in our sample (<1%), as also documented in prior studies conducted in samples ages 50 to 75 years .…”

“…Our finding that age and comorbidities were negatively associated with follow‐up is consistent with previous reports . Studies that demonstrated no significant association between follow‐up and these factors either restricted the sample to the oldest age groups or excluded those aged >75 years . It is not clear why the effects of age and comorbidity on follow‐up were not fully explained by other patient characteristics, patient behaviors (refusal, private sector colonoscopy use), physician behaviors (inappropriate screening), or environmental factors.…”

“…Potentially inappropriate screening because of limited life expectancy was relatively rare in our sample (<1%), as also documented in prior studies conducted in samples ages 50 to 75 years . The frequency of refusal among those who failed to complete a colonoscopy we observed (14%‐21%, depending on whether those who refused are combined with those who both refused and had private sector colonoscopy access) was similar to colonoscopy follow‐up refusal rates reported in prior studies (range, 7%‐26%) …”

Low rates of diagnostic colonoscopy in Federally Qualified Health Centers: A persistent problem that must be addressed to achieve the promise of colorectal cancer screening

“…The authors reported that 89% of patients with an abnormal FIT result were referred for follow‐up colonoscopy within 6 months, but only 44% actually underwent diagnostic colonoscopy. This level of follow‐up is consistent with the poor CDE rates reported in cited Veterans Administration, safety net, and other FQHC‐based studies …”

Repeated Automated Mobile Text Messaging Reminders for Follow-Up of Positive Fecal Occult Blood Tests: Randomized Controlled Trial (Preprint)

“….A delay in follow-up significantly undermines the benefits of CRC screening, including incidence, mortality, life-years saved, and net costs of screening [4][5][6][7]. Recommendations regarding the time between a positive result and colonoscopy vary between countries, ranging between 30 and 180 days [8][9][10][11][12][13]. In Israel, the Ministry of Health guidelines define the waiting period as 90 days [3,14].…”