Screening for Colorectal Cancer in a Safety-Net Health Care System: Access to Care Is Critical and Has Implications for Screening Policy

Abstract

Background: Data on the number of individuals eligible for screening, and rates of screening, are necessary to assess national colorectal cancer screening efforts. Such data are sparse for safety-net health systems. Methods: A retrospective cohort study of individuals ages 50 to 75 served by a safety-net health system in Tarrant County, TX was conducted to determine (a) the size of the potential screen-eligible population ages 50 to 75, (b) the rate of screening over 5 years among individuals ages 54 to 75, and (c) the potential predictors of screening, including sex, race/ethnicity, insurance status, frequency of outpatient visits, and socioeconomic status. Results: Of 28,708 potential screen-eligible individuals, 20,416 were ages 54 to 75 and analyzed for screening; 22.0% were screened within the preceding 5 years. Female gender, Hispanic ethnicity, ages 65 to 75, insurance status, and two or more outpatient visits were indepen-

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

“…Prior studies suggest the presence of several barriers ranging from fears of discomfort, complications, or the bowel preparation to logistical concerns including difficulty with transportation, language barriers, difficulty with scheduling appointments, or financial concerns. 20-22 Further, these barriers can be exacerbated by system-level factors such as multistep scheduling processes and/or requiring additional preoperative visits, which may exacerbate transportation and financial issues. 10, 13, 14, 20 For example, it is possible the pre-procedure visit implemented at Parkland to increase patient visit adherence may have a paradoxical effect of increasing patient barriers and decreasing diagnostic colonoscopy completion rates.…”

Association Between Primary Care Visits and Colorectal Cancer Screening Outcomes in the Era of Population Health Outreach

“…Conversely, patients who are more prevention-oriented may be both more motivated to follow up abnormal screening tests and more engaged in primary care. Previous research in primary care settings 5,6,28 and the general population 4,8 that have examined predictors of CRC screening have focused primarily on Bprevalent^screening (having ever been screened) and in settings where colonoscopy (which offers 10 years of protection) was the predominant screening modality. These studies showed that PCP visits [4][5][6][7][8] and physician recommendation were strong predictors of prevalent CRC screening (mostly with colonoscopy).…”

“…Previous research in primary care settings 5,6,28 and the general population 4,8 that have examined predictors of CRC screening have focused primarily on Bprevalent^screening (having ever been screened) and in settings where colonoscopy (which offers 10 years of protection) was the predominant screening modality. These studies showed that PCP visits [4][5][6][7][8] and physician recommendation were strong predictors of prevalent CRC screening (mostly with colonoscopy). 2,6,8 Our study extends prior work by demonstrating an independent association between prior primary care visits and subsequent Bincident^CRC screening, including outreach screening not linked directly to the primary care visit.…”

“…3 Primary care providers (PCP) traditionally initiate cancer screening, and prior work has shown that patients seen by PCPs are more likely to receive CRC screening. [4][5][6][7][8] However, CRC screening rates remain suboptimal, even after decades of public health campaigns, public reporting of health plan CRC screening rates, and implementation of visitbased preventive service reminders in electronic health records (EHRs). 4,7,[9][10][11] Therefore, a growing number of private and public health systems are taking a population health perspective and using outreach approaches to promote CRC screening that do not require a face-to-face primary care visit.…”

Use of NCCN Guidelines, Other Guidelines, and Biomarkers for Colorectal Cancer Screening

“…22 A retrospective cohort study of screening-eligible individuals in a safety-net health system reported 22% being screened in the last 5 years, and significant predictors of screening participation were female gender, Hispanic ethnicity, being between the age of 65-75 years, and having access to care. 23 Marital status is another important predictor of screening according to a large study of approximately 300,000 participants which noted that, compared to non-partnered people, married and unmarried couples were more likely to get CRC screening. 24 …”