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Petrik AF, Johnson ES, Slaughter M, Leo MC, Thompson J, Mummadi R, Jimenez R, Hussain S, Coronado G. The recalibration and redevelopment of a model to calculate patients' probability of completing a colonoscopy following an abnormal fecal test. J Med Screen 2024; 31:28-34. [PMID: 37661831 PMCID: PMC10909915 DOI: 10.1177/09691413231195568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/05/2023]
Abstract
OBJECTIVES Fecal immunochemical testing (FIT) is an effective screening tool for colorectal cancer. If an FIT is abnormal, a follow-up colonoscopy is necessary to remove polyps or find cancers. We sought to develop a usable risk prediction model to identify patients unlikely to complete a colonoscopy following an abnormal FIT test. METHODS We recalibrated and then redeveloped a prediction model in federally qualified health centers (FQHCs), using a retrospective cohort of patients aged 50-75 with an abnormal FIT test and clinical data. Logistic and Cox regressions were used to recalibrate and then redevelop the model. RESULTS The initial risk model used data from eight FQHCs (26 clinics) including 1723 patients. When we applied the model to a single large FQHC (34 clinics, 884 eligible patients), the model did not recalibrate successfully (c-statistic dropped more than 0.05, from 0.66 to 0.61). The model was redeveloped in the same FQHC in a cohort of 1401 patients with a c-statistic of 0.65. CONCLUSIONS The original model developed in a group of FQHCs did not adequately recalibrate in the single large FQHC. Health system, patient characteristics or data differences may have led to the inability to recalibrate the model. However, the redeveloped model provides an adequate model for the single FQHC.
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Affiliation(s)
- Amanda F. Petrik
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon
| | - Eric S. Johnson
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon
| | - Matthew Slaughter
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon
| | - Michael C. Leo
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon
| | - Jamie Thompson
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon
| | - Raj Mummadi
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon
| | | | - Syed Hussain
- SeaMar Community Health Centers, Seattle, Washington
| | - Gloria Coronado
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon
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Steiner JF, Nguyen AP, Schuster KS, Goodrich G, Barrow J, Steiner CA, Zeng C. Associations between Missed Colonoscopy Appointments and Multiple Prior Adherence Behaviors in an Integrated Healthcare System: An Observational Study. J Gen Intern Med 2024; 39:36-44. [PMID: 37550443 PMCID: PMC10817878 DOI: 10.1007/s11606-023-08355-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 07/25/2023] [Indexed: 08/09/2023]
Abstract
BACKGROUND Missed colonoscopy appointments delay screening and treatment for gastrointestinal disorders. Prior nonadherence with other care components may be associated with missed colonoscopy appointments. OBJECTIVE To assess variability in prior adherence behaviors and their association with missed colonoscopy appointments. DESIGN Retrospective cohort study. PARTICIPANTS Patients scheduled for colonoscopy in an integrated healthcare system between January 2016 and December 2018. MAIN MEASURES Prior adherence behaviors included: any missed outpatient appointment in the previous year; any missed gastroenterology clinic or colonoscopy appointment in the previous 2 years; and not obtaining a bowel preparation kit pre-colonoscopy. Other sociodemographic, clinical, and system characteristics were included in a multivariable model to identify independent associations between prior adherence behaviors and missed colonoscopy appointments. KEY RESULTS The median age of the 57,590 participants was 61 years; 52.8% were female and 73.4% were white. Of 77,684 colonoscopy appointments, 3,237 (4.2%) were missed. Individuals who missed colonoscopy appointments were more likely to have missed a previous primary care appointment (62.5% vs. 38.4%), a prior gastroenterology appointment (18.4% vs. 4.7%) or not to have picked up a bowel preparation kit (42.4% vs. 17.2%), all p < 0.001. Correlations between the three adherence measures were weak (phi < 0.26). The rate of missed colonoscopy appointments increased from 1.8/100 among individuals who were adherent with all three prior care components to 24.6/100 among those who were nonadherent with all three care components. All adherence variables remained independently associated with nonadherence with colonoscopy in a multivariable model that included other covariates; adjusted odds ratios (with 95% confidence intervals) were 1.6 (1.5-1.8) for outpatient appointments, 1.9 (1.7-2.1) for gastroenterology appointments, and 3.1 (2.9-3.4) for adherence with bowel preparation kits, respectively. CONCLUSIONS Three prior adherence behaviors were independently associated with missed colonoscopy appointments. Studies to predict adherence should use multiple, complementary measures of prior adherence when available.
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Affiliation(s)
- John F Steiner
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA.
- Colorado Permanente Medical Group, Denver, CO, USA.
| | - Anh P Nguyen
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
| | - Kelly S Schuster
- Department of Gastroenterology, Kaiser Permanente Colorado, Denver, CO, USA
| | - Glenn Goodrich
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
| | - Jennifer Barrow
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
| | - Claudia A Steiner
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
- Colorado Permanente Medical Group, Denver, CO, USA
| | - Chan Zeng
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
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Khoong EC, Rivadeneira NA, Pacca L, Schillinger D, Lown D, Babaria P, Gupta N, Pramanik R, Tran H, Whitezell T, Somsouk M, Sarkar U. Extent of Follow-Up on Abnormal Cancer Screening in Multiple California Public Hospital Systems: A Retrospective Review. J Gen Intern Med 2023; 38:21-29. [PMID: 35641722 PMCID: PMC9849534 DOI: 10.1007/s11606-022-07657-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 05/03/2022] [Indexed: 01/22/2023]
Abstract
BACKGROUND Inequitable follow-up of abnormal cancer screening tests may contribute to racial/ethnic disparities in colon and breast cancer outcomes. However, few multi-site studies have examined follow-up of abnormal cancer screening tests and it is unknown if racial/ethnic disparities exist. OBJECTIVE This report describes patterns of performance on follow-up of abnormal colon and breast cancer screening tests and explores the extent to which racial/ethnic disparities exist in public hospital systems. DESIGN We conducted a retrospective cohort study using data from five California public hospital systems. We used multivariable robust Poisson regression analyses to examine whether patient-level factors or site predicted receipt of follow-up test. MAIN MEASURES Using data from five public hospital systems between July 2015 and June 2017, we assessed follow-up of two screening results: (1) colonoscopy after positive fecal immunochemical tests (FIT) and (2) tissue biopsy within 21 days after a BIRADS 4/5 mammogram. KEY RESULTS Of 4132 abnormal FITs, 1736 (42%) received a follow-up colonoscopy. Older age, Medicaid insurance, lack of insurance, English language, and site were negatively associated with follow-up colonoscopy, while Hispanic ethnicity and Asian race were positively associated with follow-up colonoscopy. Of 1702 BIRADS 4/5 mammograms, 1082 (64%) received a timely biopsy; only site was associated with timely follow-up biopsy. CONCLUSION Despite the vulnerabilities of public-hospital-system patients, follow-up of abnormal cancer screening tests occurs at rates similar to that of patients in other healthcare settings, with colon cancer screening test follow-up occurring at lower rates than follow-up of breast cancer screening tests. Site-level factors have larger, more consistent impact on follow-up rates than patient sociodemographic traits. Resources are needed to identify health system-level factors, such as test follow-up processes or data infrastructure, that improve abnormal cancer screening test follow-up so that effective health system-level interventions can be evaluated and disseminated.
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Affiliation(s)
- Elaine C Khoong
- Division of General Internal Medicine at Zuckerberg San Francisco General Hospital, Department of Medicine, University of California San Francisco, San Francisco, CA, USA. .,UCSF Center for Vulnerable Populations at Zuckerberg San Francisco General Hospital, San Francisco, CA, USA.
| | - Natalie A Rivadeneira
- Division of General Internal Medicine at Zuckerberg San Francisco General Hospital, Department of Medicine, University of California San Francisco, San Francisco, CA, USA.,UCSF Center for Vulnerable Populations at Zuckerberg San Francisco General Hospital, San Francisco, CA, USA
| | - Lucia Pacca
- Division of General Internal Medicine at Zuckerberg San Francisco General Hospital, Department of Medicine, University of California San Francisco, San Francisco, CA, USA.,UCSF Center for Vulnerable Populations at Zuckerberg San Francisco General Hospital, San Francisco, CA, USA
| | - Dean Schillinger
- Division of General Internal Medicine at Zuckerberg San Francisco General Hospital, Department of Medicine, University of California San Francisco, San Francisco, CA, USA.,UCSF Center for Vulnerable Populations at Zuckerberg San Francisco General Hospital, San Francisco, CA, USA
| | - David Lown
- California Health Care Safety Net Institute, Oakland, CA, USA
| | - Palav Babaria
- Division of General Internal Medicine at Zuckerberg San Francisco General Hospital, Department of Medicine, University of California San Francisco, San Francisco, CA, USA.,Alameda Health System, Oakland, CA, USA
| | | | - Rajiv Pramanik
- Office of Informatics & Technology and Department of Emergency Medicine, Contra Costa Health Services, Martinez, CA, USA
| | - Helen Tran
- Department of Family Medicine, Charles R. Drew University College of Medicine, Los Angeles, CA, USA.,Department of Health Services at Los Angeles County, Los Angeles, CA, USA
| | | | - Ma Somsouk
- UCSF Center for Vulnerable Populations at Zuckerberg San Francisco General Hospital, San Francisco, CA, USA.,Division of Gastroenterology, Department of Medicine, UCSF, San Francisco, CA, USA
| | - Urmimala Sarkar
- Division of General Internal Medicine at Zuckerberg San Francisco General Hospital, Department of Medicine, University of California San Francisco, San Francisco, CA, USA.,UCSF Center for Vulnerable Populations at Zuckerberg San Francisco General Hospital, San Francisco, CA, USA
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Murphy CC, Halm EA, Zaki T, Johnson C, Yekkaluri S, Quirk L, Singal AG. Colorectal Cancer Screening and Yield in a Mailed Outreach Program in a Safety-Net Healthcare System. Dig Dis Sci 2022; 67:4403-4409. [PMID: 34800219 PMCID: PMC8605769 DOI: 10.1007/s10620-021-07313-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Accepted: 10/26/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND Screening with fecal immunochemical testing (FIT) reduces colorectal cancer mortality; however, screening remains low in underserved populations. Mailed outreach, including an invitation letter, FIT, and test instructions, is an evidence-based strategy to improve screening. AIMS To examine screening completion and yield in a mailed outreach program in a safety-net healthcare system. METHODS We identified and mailed outreach invitations to patients due for screening in a large safety-net system between September 1, 2018, and August 31, 2019. We examined: (1) screening completion, the proportion of patients completing FIT or screening colonoscopy within 6 months of the mailed invitation; and (2) timely diagnostic colonoscopy, the proportion of patients completing colonoscopy within 6 months of positive FIT. RESULTS We mailed 14,879 invitations to 13,190 patients. Nearly half (n = 6098, 46.2%) of patients completed screening: 4,896 (80.3%) completed FIT through mailed outreach; 1,114 (18.3%) FIT through usual care; and 88 (1.4%) screening colonoscopy through usual care. Of patients with a positive FIT (n = 289), 50.5% completed diagnostic colonoscopy within 6 months, 10.7% within 6-12 months, and 4.8% after 12 months. A total of 8 cancers and 83 advanced adenomas were detected in the 191 patients completing diagnostic colonoscopy. CONCLUSION After implementing and scaling up mailed outreach in a safety-net system, about half of patients completed screening, and the majority did so through mailed outreach. However, many patients failed to complete diagnostic colonoscopy after positive FIT. Results highlight the importance of adapting mailed outreach programs to local contexts and constraints of healthcare systems, in order to support efforts to improve CRC screening in underserved populations.
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Affiliation(s)
- Caitlin C. Murphy
- School of Public Health, University of Texas Health Science Center at Houston, 7000 Fannin St., Ste. 2618, Houston, TX 77030 USA
| | - Ethan A. Halm
- Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX USA
| | - Timothy Zaki
- Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX USA
| | - Carmen Johnson
- Population & Data Sciences, University of Texas Southwestern Medical Center, Dallas, TX USA
| | - Sruthi Yekkaluri
- Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX USA
| | - Lisa Quirk
- Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX USA
| | - Amit G. Singal
- Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX USA
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Coronado GD, Rawlings AM, Petrik AF, Slaughter M, Johnson ES, Hannon PA, Cole A, Vu T, Mummadi RR. Precision Patient Navigation to Improve Rates of Follow-up Colonoscopy, An Individual Randomized Effectiveness Trial. Cancer Epidemiol Biomarkers Prev 2021; 30:2327-2333. [PMID: 34583969 PMCID: PMC9273475 DOI: 10.1158/1055-9965.epi-20-1793] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 02/17/2021] [Accepted: 09/22/2021] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Colorectal cancer screening by annual fecal immunochemical test (FIT) with follow-up on abnormal results is a cost-effective strategy to reduce colorectal cancer incidence and mortality. Unfortunately, many patients with abnormal results do not complete a follow-up colonoscopy. We tested whether navigation targeted to patients who are unlikely to complete the procedure may improve adherence and long-term outcomes. METHODS Study participants were patients at a large, integrated health system (Kaiser Permanente Northwest) who were ages 50 to 75 and were due for a follow-up colonoscopy after a recent abnormal FIT result. Probability of adherence to follow-up was estimated at baseline using a predictive risk model. Patients whose probability was 70% or lower were randomized to receive patient navigation or usual care, with randomization stratified by probability category (<50%, 50% < 60%, 60% < 65%, 65% ≤ 70%). We compared colonoscopy completion within 6 months between the navigation and usual care groups using Cox proportional hazards regression. RESULTS Participants (n = 415; 200 assigned to patient navigation, 215 to usual care) had a mean age of 62 years, 54% were female, and 87% were non-Hispanic white. By 6 months, 76% of the patient navigation group had completed a colonoscopy, compared with 65% of the usual care group (HR = 1.35; 95% confidence interval, 1.07-1.72; log-rank P value = 0.027). CONCLUSIONS In this randomized trial, patient navigation led to improvements in follow-up colonoscopy adherence. IMPACT More research is needed to assess the value of precision-directed navigation programs.
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Affiliation(s)
- Gloria D Coronado
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon.
| | - Andreea M Rawlings
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Amanda F Petrik
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon
| | - Matthew Slaughter
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon
| | - Eric S Johnson
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon
- Northwest Permanente Medicine, Portland, Oregon
| | - Peggy A Hannon
- University of Washington School of Public Health, Seattle, Washington
| | - Allison Cole
- University of Washington School of Public Health, Seattle, Washington
- University of Washington School of Medicine, Seattle, Washington
| | - Thuy Vu
- University of Washington School of Public Health, Seattle, Washington
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