Barriers to completing colonoscopy after a positive fecal occult blood test

Abstract

Background Colorectal cancer leads to significant morbidity and mortality. Early detection and treatment are essential. Screening using fecal occult blood tests has increased significantly, but adherence to colonoscopy follow-up is suboptimal, increasing CRC mortality risk. The aim of this study was to identify barriers to colonoscopy following a positive FOBT at the level of the patient, physician, organization and policymakers. Methods This mixed methods study was conducted at two health care organizations in Israel. The study included retrospective analyses of 45,281 50–74 year-old members with positive fecal immunochemical tests from 2010 to 2014, and a survey of 772 patients with a positive test during 2015, with and without follow-up. The qualitative part of the study included focus groups with primary physicians and gastroenterologists and in-depth interviews with opinion leaders in healthcare. Results Patient lack of comprehension regarding the test was the strongest predictor of non-adherence to follow-up. Older age, Arab ethnicity, and lower socio economic status significantly reduced adherence. We found no correlation with gender, marital status, patient activation, waiting time for appointments or distance from gastroenterology clinics. Primary care physicians underestimate non-adherence rates. They feel responsible for patient follow-up, but express lack of time and skills that will allow them to ensure adherence among their patients. Gastroenterologists do not consider fecal occult blood an effective tool for CRC detection, and believe that all patients should undergo colonoscopy. Opinion leaders in the healthcare field do not prioritize the issue of follow-up after a positive screening test for colorectal cancer, although they understand the importance. Conclusions We identified important barriers that need to be addressed to improve the effectiveness of the screening program. Targeted interventions for populations at risk for non-adherence, specifically for those with low literacy levels, and better explanation of the need for follow-up as a routine need to be set in place. Lack of agreement between screening recommendations and gastroenterologist opinion, and lack of awareness among healthcare authority figures negatively impact the screening program need to be addressed at the organizational and national level. Trial registration This study was approved by the IRB in both participating organizations (Meuhedet Health Care Institutional Review Board #02–2–5-15, Maccabi Healthcare Institutional Review Board BBI-0025-16). Participant consent was waived by both IRB’s.

Third Asia-Pacific consensus recommendations on colorectal cancer screening and postpolypectomy surveillance

“…Recommendation by a physician is the strongest factor motivating people to go for screening in the opportunistic setting 151 152. As for the compliance to follow-up procedures after a positive FIT, lack of comprehension about the test was the strongest predictor of non-adherence, whereas higher socioeconomic status, higher perceived threat, higher cues for action, lower perceived barriers, and higher health behaviour scores were identified as factors associated with a greater willingness to undergo diagnostic colonoscopy after a positive FIT 153 154. Individual programmes should increase efforts to remove or overcome those barriers to follow-up colonoscopy, thereby maximising the effectiveness of the screening.…”

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

“…Awareness about how mixed-methods approaches could help improve follow-up colonoscopy is increasing ( Azulay et al, 2021 , Bertels et al, 2022 , Selby et al, 2019 ). In an Israeli population, Azulay et al found in telephone surveys (quantitative) that lack of comprehension regarding test completion, the abnormal result, and subsequent recommendations were the strongest predictors for lack of follow-up.…”

“…In an Israeli population, Azulay et al found in telephone surveys (quantitative) that lack of comprehension regarding test completion, the abnormal result, and subsequent recommendations were the strongest predictors for lack of follow-up. In their qualitative analysis (focus groups and in-depth interviews), the authors found that lack of test results awareness and physician workload, were the most frequently reported reasons for lack of follow-up colonoscopy ( Azulay et al, 2021 ). These results differ from our study where the most common EHR documented (quantitative) barrier to follow-up colonoscopy was patient declining the procedure and the most common patient-reported (qualitative) barrier was fear of the procedure.…”

Comorbidities and Risk Factors of Patients Diagnosed with CRC after Positive Fecal Test in Real Life

“…In fact, adherence to colonoscopy was intensely researched among patients who had positive FOBT and there are several reasons for barriers to endoscopic follow-up, including the four main groups: information technology (IT) [ 19 , 20 ], healthcare organizations [ 21 , 22 ], physician behavior [ 23 , 24 , 25 , 26 ], and patient emotional and cognitive factors [ 27 , 28 , 29 , 30 ]. In addition, barriers could affect adherence to colonoscopy and the barriers could be related to the patients, providers, and system barriers [ 31 ].…”