Abnormal Colorectal Cancer Test Follow-Up: A Quality Improvement Initiative at a Federally Qualified Health Center

INTRODUCTION/OBJECTIVES

Colonoscopy completion rates after an abnormal fecal immunochemical test (FIT) are suboptimal, resulting in missed opportunities for early detection and prevention of colorectal cancer. Patient navigation and structured follow-up may improve colonoscopy completion, but implementation of these strategies is not widespread.

METHODS

We conducted a quality improvement study using a Plan-Do-Study-Act (PDSA) Model to increase colonoscopy completion after abnormal FIT in a large federally qualified health center serving a diverse and low-income population. Intervention components included patient navigation, and a checklist to promote completion of key steps required for abnormal FIT follow-up. Primary outcome was proportion of patients achieving colonoscopy completion within 6 months of abnormal FIT, assessed at baseline for 156 patients pre-intervention, and compared to 208 patients during the intervention period from April 2017 to December 2019. Drop offs at each step in the follow-up process were assessed.

RESULTS

Colonoscopy completion improved from 21% among 156 patients with abnormal FIT pre-intervention, to 38% among 208 patients with abnormal FIT during the intervention (P < .001; absolute increase: 17%, 95% CI: 6.9%-25.2%). Among the 130 non-completers during the intervention period, lack of completion was attributable to absence of colonoscopy referral for 7.7%; inability to schedule a pre-colonoscopy specialist visit for 71.5%; failure to complete a pre-colonoscopy visit for 2.3%; the absence of colonoscopy scheduling for 9.2%; failure to show for a scheduled colonoscopy for 9.2%.

CONCLUSIONS

Patient navigation and structured follow-up appear to improve colonoscopy completion after abnormal FIT. Additional strategies are needed to achieve optimal rates of completion.

Comparing Latino Community Members' and Clinical Staff's Perspectives on Barriers and Facilitators to Colorectal Cancer Screening

Latinos in the United States have low rates of colorectal cancer (CRC) screening even though CRC is the third leading cause of cancer death among Latinos. This qualitative study aimed to understand and compare the perspectives of clinical staff (CS) and Latino community members (LCMs) in an urban Southern California community regarding barriers and facilitators of CRC screening. Through purposive sampling, 39 LCMs (mean age: 59.4 years, 79.5% female) were recruited to participate in one of five focus groups, and 17 CS (mean age: 38.8 years, 64.7% female) were recruited to participate in semi-structured in-depth interviews, along with a demographic survey. Interviews and focus group recordings were transcribed verbatim, translated, and analyzed using direct content analysis. Demographic data were summarized using descriptive statistics. Findings suggest that CS and LCMs have both similar and opposing perspectives with regard to barriers and facilitators of CRC screening. Themes discussed included attitudes towards CRC screening, CRC knowledge, access to resources, commitments and responsibilities, social support, vicarious learning, patient-provider communication, trust, and social relationships. Study findings can be used to guide interventions and policies to improve access to CRC screening among LCMs.

A Promotor-Led Pilot Study to Increase Colorectal Cancer Screening in Latinos: The Juntos Contra El Cáncer Program

Background. Latinos have lower colorectal cancer (CRC) screening rates compared to other racial/ethnic groups in the United States, despite an overall increase in CRC screening over the past 10 years. To address this disparity, we implemented a promotor-led intervention to increase CRC screening test adherence in community-based settings, connecting community members with a partnering federally qualified health center. Purpose. To evaluate the Juntos Contra el Cáncer/Together Against Cancer (JUNTOS) intervention, by assessing pre-post changes in (1) CRC screening test adherence and (2) CRC knowledge and perceived barriers to CRC screening. We also assessed the feasibility and acceptability of program activities. Method. JUNTOS was a group-based intervention, delivered by promotores (community health workers), to promote CRC screening test adherence among Latino adults. The intervention consisted of a culturally tailored 2½-hour interactive workshop followed by an appointment scheduling assistance from a promotor. Workshop participants were Latino adults (males and females) aged 50 to 75 years who were not up-to-date with CRC screening guidelines. We conducted interviews before and 6 to 9 months after the workshop to assess program outcomes. Results. Of the 177 participants included, 118 reported completing the CRC screening test (66.7%) by 6 to 9 months postintervention. We observed baseline to 6- to 9-month increase in CRC knowledge and lower perceived barriers to obtaining CRC screening. Furthermore, the intervention was found to be feasible and acceptable. Conclusion. Results suggest that JUNTOS can be feasibly implemented in partnership with a federally qualified health center. The current study supports group-based CRC interventions in community and clinic settings.

Abstract C106: Multilevel patient navigator-led intervention to optimize colonoscopy completion after an abnormal fecal immunochemical test

Purpose: Impact of colorectal cancer (CRC) screening with the fecal immunochemical test (FIT) depends on completion of diagnostic colonoscopy after abnormal FIT, as failure to complete diagnostic colonoscopy is associated with 2.4 fold increased risk of CRC death. Colonoscopy completion after abnormal FIT ranges from 18% to 57% among Federally Qualified Health Centers (FQHCs) in San Diego County. Our goal is to report the initial successes and challenges of a multi-level, patient navigator (PN) led intervention to optimize colonoscopy completion after abnormal FIT faced largely by Hispanic/Latino patients in our geographic area. Methods: At a single primary clinic within a large FQHC in San Diego’s predominantly Latino community, we implemented a multi- component intervention to promote colonoscopy completion for patients with abnormal FIT led by a bilingual/bicultural PN. PN responsibilities included monitoring timely review of FIT results by ordering provider, results provision to patients, insurance authorization, facilitating referrals for GI consultation and colonoscopy scheduling. Health system barriers (such as failure to order colonoscopy) were addressed by having the PN prompt the relevant team member to complete required care steps. Patient barriers (such as understanding FIT results, procedure scheduling and fears) were addressed through phone and in-person encounters by the PN. Summary: During the period of March to August 2017, 45 patients had an abnormal FIT. Out of 45 patients, three were not eligible for navigation due to prior colonoscopy completion. Of the remaining 42, 26 did not complete colonoscopy (14 lost to follow-up, 4 pending GI consult, 4 pending colonoscopy, 4 declined). The PN directly interacted with 28 patients of which 16 (57%) successfully completed colonoscopy. These preliminary results show a low overall rate of colonoscopy completion (16/45=36%) with nearly one third of patients (14/45=31%) lost to follow-up. Conclusions: In our initial experience with a PN-led, multi-level intervention for promoting colonoscopy completion after abnormal FIT, 57% of patients who interacted with the PN completed a colonoscopy procedure. Challenges such as loss to follow up remain a barrier to intervention success. Our results suggest that multi-level interventions led by a PN have potential to optimize follow through of colonoscopy completion after abnormal FIT.

Citation Format: Monica Hernandez, Jesse Nodora, Balambal Bharti, Jose L Diaz, Jessica Marquez, Felipe Garcia-Bigley, Christian Ramers, Jessica Haughton, Elva Arredondo, Samir Gupta. Multilevel patient navigator-led intervention to optimize colonoscopy completion after an abnormal fecal immunochemical test [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr C106.

Diagnostic colonoscopy completion after abnormal fecal immunochemical testing and quality of tests used at 8 Federally Qualified Health Centers in Southern California: Opportunities for improving screening outcomes

BACKGROUND

The effectiveness of colorectal cancer screening with fecal immunochemical tests (FITs) of stool blood depends on high rates of colonoscopy follow-up for abnormal FITs and the use of high-quality tests. This study characterized colonoscopy referral and completion among patients with abnormal FITs and the types of FITs implemented in a sample of Southern California Federally Qualified Health Centers (FQHCs).

METHODS

FQHCs in San Diego, Imperial, and Los Angeles Counties were invited to define a cohort of ≥150 consecutive patients with abnormal FITs in 2015-2016 and to provide data on sex, insurance status, diagnostic colonoscopy referrals and completion within 6 months of abnormal FITs, and the types (brands) of FITs implemented. The primary outcomes were the proportions with colonoscopy referrals and completion for all patients at each FQHC and in aggregate.

RESULTS

Eight FQHCs provided data for 1229 patients with abnormal FITs; 46% were male, and 20% were uninsured. Among patients with abnormal FITs, 89% (1091 of 1229; 95% confidence interval [CI], 0.87-0.91) had a colonoscopy referral, and 44% (539 of 1229; 95% CI, 0.41-0.47) had colonoscopy completion. Across FQHCs, the range for colonoscopy referral was 73% to 96%, and the range for completion was 18% to 57%. Six of the 8 FQHCs (75%) reported FIT brands with limited data to support their effectiveness.

CONCLUSIONS

In a sample of Southern California FQHCs, diagnostic colonoscopy completion after abnormal FITs was substantially below the nationally recommended benchmark to achieve 80% completion, and the use of FIT brands with limited data to support their effectiveness was high. These findings suggest a need for policies and multilevel interventions to promote diagnostic colonoscopy among individuals with abnormal FITs and the use of higher quality FITs.