Patient-, Provider-, and System-Level Factors in Low Adherence to Surveillance Colonoscopy Guidelines: Implications for Future Interventions

Evaluation of a multimedia outreach campaign for a multi-target stool DNA test for colorectal cancer screening among non-medicare employer population in the United States

Regular and timely screenings for colorectal cancer (CRC) can improve survival through early cancer detection. The current prospective intervention study assessed the effectiveness of a CRC screening outreach campaign via a multi-media campaign featuring articles in a multi-topic benefits newsletter that was both printed/mailed to homes and emailed to Metro Nashville Public Schools (MNPS) employees and their dependents in the United States. Individuals were included if they were between 45 and 64 years old. The mailed newsletter was sent to 5631 active employees, 868 under 65 retirees, and 4046 retirees with Medicare. The open rate was the highest for the third email (n = 3018; 53.3%). The click-through rate was also the highest for the third email (n = 203;6.7%). Among those who opened at least one of the emails or received a mailed newsletter, 119 members completed the assessment (conversion rate = 3.9%). Among this population, the mt-sDNA completion rate was 64.5% (69 orders completed out of 107 ordered mt-sDNA kits). All 6 patients with a positive mt-sDNA result underwent a follow-up colonoscopy (FU-CY) with the mean (±SD) days to FU-CY among those with positive mt-sDNA test results was 49 (±27) days (median = 42 days). Using emails in conjunction with other targeted interventions to outreach and educate members regarding CRC screening may be an effective strategy to enhance mt-sDNA completion rates.

Automated identification and assignment of colonoscopy surveillance recommendations for individuals with colorectal polyps

BACKGROUND AND AIMS

Determining surveillance intervals for patients with colorectal polyps is critical but time-consuming and challenging to do reliably. We present the development and assessment of a pipeline that leverages natural language processing techniques to automatically extract and analyze relevant polyp findings from free-text colonoscopy and pathology reports. Using this information, we categorized individual patients into 6 postcolonoscopy surveillance intervals defined by the U.S. Multi-Society Task Force on Colorectal Cancer.

METHODS

Using a set of 546 randomly selected colonoscopy and pathology reports from 324 patients in a single health system, we used a combination of statistical classifiers and rule-based methods to extract polyp properties from each report type, associate properties with unique polyps, and classify a patient into 1 of 6 risk categories by integrating information from both report types. We then assessed the pipeline's performance by determining the positive predictive value (PPV), sensitivity, and F-score of the algorithm, compared with the determination of surveillance intervals by a gastroenterologist.

RESULTS

The pipeline was developed using 346 reports (224 colonoscopy and 122 pathology) from 224 patients and evaluated on an independent test set of 200 reports (100 colonoscopy and 100 pathology) from 100 patients. We achieved an average PPV, sensitivity, and F-score of .92, .95, and .93, respectively, across targeted entities for colonoscopy. Pathology extraction achieved a PPV, sensitivity, and F-score of .95, .97, and .96. The system achieved an overall accuracy of 92% in assigning the recommended interval for surveillance colonoscopy.

CONCLUSIONS

This study demonstrates the feasibility of using machine learning to automatically extract findings and classify patients to appropriate risk categories and corresponding surveillance intervals. Incorporating this system can facilitate proactive and timely follow-up after screening colonoscopy and enable real-time quality assessment of prevention programs and providers.

Evaluating Outreach Methods for Multi-Target Stool DNA Test for Colorectal Cancer Screening Among an Employer Population

Introduction/Objectives:

Despite compelling evidence of clinical and economic benefits, adherence to colorectal cancer (CRC) screening remains low. Increasing public awareness through various outreach methods may improve screening uptake. The objective of this study was to evaluate the uptake of non-invasive multi-target stool DNA (mt-sDNA) by different outreach methods in an average-risk employer population.

Methods:

This retrospective observational study included CRC screening-eligible individuals aged ≥50 years insured by the Metropolitan Nashville Public Schools (MNPS) employee healthcare plan. The study intervention arms included population-based outreach and office visit-based interaction. The mt-sDNA completion rate (proportion of individuals who return the mt-sDNA kit after consenting to have it shipped to their home), proportion of patients who performed follow-up colonoscopy after a positive test, and time to follow-up colonoscopy were assessed.

Results:

A total of 167 mt-sDNA kits were shipped to eligible participants (aged 50-64 years) in the population-based outreach arm. In the office visit-based interaction arm, a total of 132 mt-sDNA kits were shipped to eligible participants (aged ≥50 years). The mt-sDNA completion rate was significantly higher for office visit-based interaction as compared to population-based outreach (76.8% vs 53.5%; P < .001) among those aged 50 to 64 years. While all patients aged 50 to 64 years with a positive mt-sDNA result received a follow-up colonoscopy in both arms, the median time to follow-up colonoscopy was shorter among the population-based outreach (55 vs 136 days; P < .05).

Conclusions:

Office visit-based interaction was associated with a higher mt-sDNA completion rate as compared to the population-based outreach among average-risk, CRC screening-eligible individuals aged 50 to 64 years old.

Gastroenterology visitation and reminders predict surveillance uptake for patients with adenomas with high-risk features

Individuals diagnosed with colorectal adenomas with high-risk features during screening colonoscopy have increased risk for the development of subsequent adenomas and colorectal cancer. While US guidelines recommend surveillance colonoscopy at 3 years in this high-risk population, surveillance uptake is suboptimal. To inform future interventions to improve surveillance uptake, we sought to assess surveillance rates and identify facilitators of uptake in a large integrated health system. We utilized a cohort of patients with a diagnosis of ≥ 1 tubular adenoma (TA) with high-risk features (TA ≥ 1 cm, TA with villous features, TA with high-grade dysplasia, or ≥ 3 TA of any size) on colonoscopy between 2013 and 2016. Surveillance colonoscopy completion within 3.5 years of diagnosis of an adenoma with high-risk features was our primary outcome. We evaluated surveillance uptake over time and utilized logistic regression to detect factors associated with completion of surveillance colonoscopy. The final cohort was comprised of 405 patients. 172 (42.5%) patients successfully completed surveillance colonoscopy by 3.5 years. Use of a patient reminder (telephone, electronic message, or letter) for due surveillance (adjusted odds = 1.9; 95%CI = 1.2-2.8) and having ≥ 1 gastroenterology (GI) visit after diagnosis of an adenoma with high-risk features (adjusted odds = 2.6; 95%CI = 1.6-4.2) significantly predicted surveillance colonoscopy completion at 3.5 years. For patients diagnosed with adenomas with high-risk features, surveillance colonoscopy uptake is suboptimal and frequently occurs after the 3-year surveillance recommendation. Patient reminders and visitation with GI after index colonoscopy are associated with timely surveillance completion. Our findings highlight potential health system interventions to increase timely surveillance uptake for patients diagnosed with adenomas with high-risk features.

Receipt of Colonoscopy Following Diagnosis of Advanced Adenomas: An Analysis within Integrated Healthcare Delivery Systems

BACKGROUND

To reduce colorectal cancer incidence and mortality, experts recommend surveillance colonoscopy 3 years after advanced adenoma removal. Little is known about adherence to that interval.

METHODS

We describe patterns of and factors associated with subsequent colonoscopy among persons with ≥3 adenomas and/or ≥1 adenoma with villous/tubulovillous histology in four U.S. integrated healthcare delivery systems. We report Kaplan-Meier estimators of the cumulative percentage of patients undergoing colonoscopy 6 months to 3.5 years after an index colonoscopy with high-risk findings. Combining data from three healthcare systems, we used multivariable logistic regression with inverse probability of censoring weights to estimate ORs and 95% confidence intervals (CI) for associations between patient characteristics and receipt of subsequent colonoscopy.

RESULTS

Among 6,909 persons with advanced adenomas, the percent receiving a subsequent colonoscopy 6 months to 3.5 years later ranged from 18.3% (95% CI: 11.7%-27.8%) to 59.5% (95% CI: 53.8%-65.2%) across healthcare systems. Differences remained significant in the multivariable model. Patients with ≥3 adenomas were more likely than those with 1 to 2 villous/tubulovillous adenomas to undergo subsequent colonoscopy. Subsequent colonoscopy was also more common for patients ages 60-74 and less common for patients ages 80 to 89 compared with those ages 50 to 54 years at their index colonoscopy. Sex, race/ethnicity, and comorbidity index score were generally not associated with subsequent colonoscopy receipt.

CONCLUSIONS

Colonoscopy within the recommended interval following advanced adenoma was underutilized and varied by healthcare system, age, and number of adenomas.

IMPACT

Strategies to improve adherence to surveillance colonoscopy following advanced adenomas are needed.

Adherence to follow-up in high-risk adenoma patients diagnosed by, and excluded from the Barcelona colorectal cancer screening programme

INTRODUCTION

Colorectal cancer screening programmes have been shown to reduce incidence and mortality. High-risk adenomas (HRA) are the most frequently diagnosed lesions in these programmes, and these patients are referred to a specialist. However, few studies have evaluated the adherence of HRA patients to the recommended endoscopic follow-up.

OBJECTIVES

To analyse follow-up adherence and duration in patients diagnosed with HRA in a screening programme.

METHODS

Retrospective cohort study of patients diagnosed with HRA within one of the participating hospitals of the colorectal cancer screening programme of Barcelona, during the first round of the programme (2010-2011). The follow-up period was 75.5 months. Descriptive analyses, logistic regression and survival models were performed.

RESULTS

602 patients were included in the study, 66.6% of which were men. The adherence rate was 83.7% (n=504). Follow-up colonoscopy was performed within the recommended time (36±6months) in 57.7%, with a mean follow-up of 34 months. The Cox regression only showed differences at the socioeconomic level, with a lower adherence rate in the most deprived quintile (HR 0.70; 95% CI, 0.53-0.93).

CONCLUSIONS

Compared to previous studies, the follow-up adherence rate is considered to be acceptable. However, follow-up was not performed within the recommended time frame in a high proportion of cases. There is a need to further explore the reasons leading to lower follow-up adherence in the most deprived socioeconomic group and to increase the equity of the programme beyond participation.

Examining racial disparities in colon cancer clinical delay in the Colon Cancer Patterns of Care in Chicago study

PURPOSE

We explored a potential racial disparity in clinical delay among non-Hispanic (nH) Black and White colon cancer patients and examined factors that might account for the observed disparity.

METHODS

Patients aged 30-79 years with a newly diagnosed colon cancer from 2010 to 2014 (n = 386) were recruited from a diverse sample of nine public, private, and academic hospitals in and around Chicago. Prolonged clinical delay was defined as 60 days or more or 90 days or more between medical presentation (symptoms or a screen-detected lesion) and treatment initiation (surgery or chemotherapy). Multivariable logistic regression with model-based standardization was used to estimate the disparity as a difference in prevalence of prolonged delay by race.

RESULTS

Prevalence of delay in excess of 60 days was 12 percentage points (95% confidence interval: 2%, 22%) higher among nH Blacks versus Whites after adjusting for age, facility, and county of residence. Travel burden (time and distance traveled from residence to facility) explained roughly one-third of the disparity (33%, P = .05), individual and area-level socioeconomic status measures explained roughly one-half (51%, P = .21), and socioeconomic measures together with travel burden explained roughly four-fifths (79%, P = .08).

CONCLUSIONS

Low socioeconomic status and increased travel burden are barriers to care disproportionately experienced by nH Black colon cancer patients.

Knowledge of Polyp History and Recommended Follow-Up Among a Predominately African American Patient Population and the Impact of Patient Navigation

BACKGROUND AND AIMS

Colorectal screening (CRS) rates in minority and uninsured populations have increased through patient navigation (PN) interventions. However, patient knowledge of colonoscopy results and follow-up recommendations has not been described in an African American (AA) population or following PN. Our objectives were to determine patient knowledge of colonoscopy results and follow-up recommendations within an AA patient population and to compare post-colonoscopy knowledge among patients who received either PN or usual care.

METHODS

This is a prospective observational study of patients who completed a screening colonoscopy in 2014. A semi-structured telephone survey was completed by 96 participants (69 % AA, 78 % female, and mean age 63 years). The survey assessed patient recall of polyp results and follow-up recommendations. Responses were compared with the medical record.

RESULTS

Of 96 patients surveyed (response rate, 68 %), 83 % accurately reported if polyps were detected and 66 % accurately reported their recommended follow-up. The identification of adenomatous polyps on colonoscopy was a predictor of accurate recall of colonoscopy results and follow-up recommendations. Uninsured patients who completed PN (18 of 96) were more likely to accurately report polyp results (100 vs. 80 %; P = 0.036), but the rates of accurate follow-up recall were not statistically significant (44 vs. 71 %; P = 0.053) when compared to usual care patients.

CONCLUSIONS

In an AA population, post-colonoscopy polyp recall rates were similar to those described in white populations. Uninsured patients who completed PN were more likely than insured usual care patients to accurately report the presence of polyps on colonoscopy.