Reasons for Lack of Diagnostic Colonoscopy After Positive Result on Fecal Immunochemical Test in a Safety-Net Health System

Abstract

Background Effective colorectal cancer screening depends on timely diagnostic evaluation in patients with abnormal fecal immunochemical tests (FIT). Although prior studies suggest low rates of follow-up colonoscopy, there is little information among patients in safety-net health systems and few data characterizing reasons for low follow-up rates. Aims Characterize factors contributing to lack of follow-up colonoscopy in a racially diverse and socioeconomically disadvantaged cohort of patients with abnormal FIT receiving care in an integrated safety-net health system. Methods We performed a retrospective electronic medical record review of patients aged 50-64 years with abnormal FIT at a population-based safety-net health system between January 2010 and July 2013. Review of electronic medical record focused on patients without follow-up colonoscopy to characterize patient-, provider-, and system-level reasons for lack of diagnostic evaluation. We used logistic regression analysis to identify predictors of follow-up colonoscopy within 12 months of abnormal FIT. Results Of 1267 patients with abnormal FIT, 536 (42.3%) failed to undergo follow-up colonoscopy within one year. Failure was attributable to patient-level factors in 307 (57%) cases, provider factors in 97 (18%) cases, system factors in 118 (22%) cases. In multivariate analysis, follow-up colonoscopy was less likely among those aged 61-64 years (OR 0.63, 95%CI 0.46–0.87) compared to 50-55 year-olds. Conclusions Nearly half (42%) of patients with abnormal FIT failed to undergo follow-up colonoscopy within one year. Lack of diagnostic evaluation is related to a combination of patient-, provider-, and system-level factors, highlighting the need for multi-level interventions to improve follow-up colonoscopy completion rates.

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 …”

Interventions to Improve Follow-up of Positive Results on Fecal Blood Tests

“…Colonoscopy follow-up is complex because it involves the interaction of several levels of care and evaluating the appropriateness of an invasive diagnostic test (16, 17). Several patient-, provider-, and system-level factors have been evaluated to improve follow-up of test-positive patients (13, 18–21), but lack of comparative data impedes implementation of potentially effective interventions.…”

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

“…The interventions were effective for short-term but not long-term, follow-up. Several studies have described interventions aimed at increasing follow-up rates and showed mixed results [13,19,[27][28][29][30][31][32][33][34][35][36][37][38][39][40]. When the patient and physician's relations are good and based on clear communication and trust, the patient will be more likely to adhere to and fulfill the physicians' instructions [41,42].…”

“…Barriers to follow-up after a positive FOBT have been identified in the literature [17][18][19][20][21][22] and are divided into four general groups based on whether they are related to patients, physicians, providers, or information technology [23][24][25]. Intervention programs have been developed to target each of these groups [26].…”