Many Safety Net Patients Don’t Complete Colonoscopy after Abnormal Stool-Based Colorectal Screening Test

UCSF Study Recommends Multilevel Intervention to Increase Participation

By Scott Maier

Nearly half of the patients in a safety net health system who had an abnormal stool-based screening test for colorectal cancer failed to receive the recommended colonoscopy within a year, despite the benefits of an integrated health care system with access to colonoscopy and shared electronic health records, according to researchers at UC San Francisco. They suggest a multilevel intervention approach to increase participation.

The study appears online Dec. 13, 2016, in The American Journal of Gastroenterology.

“Much has been published about non-invasive screening tests for colon cancer, but there are few reports on how patients with abnormal results do in follow up,” said lead author Rachel Issaka, MD, gastroenterology fellow at UCSF and the Priscilla Chan and Mark Zuckerberg San Francisco General Hospital and Trauma Center (ZSFG).

Colorectal cancer is the second leading cause of U.S. cancer deaths. Even with evidence that screening is effective in reducing mortality, it remains underutilized in the general population, especially among racial/ethnic minorities and low-income populations.

In safety net health care settings, which provide significant care to low-income, uninsured and vulnerable populations, a stool-based screening test called the fecal immunochemical test (FIT) is often promoted because of patient preference and limited colonoscopy resources. FIT, recommended by the American Cancer Society for screening, looks for microscopic levels of blood in the stool. As the risk of colorectal cancer is more than 10 times higher after an abnormal stool test, a subsequent diagnostic colonoscopy is strongly recommended.

Study Utilizes the San Francisco Health Network

In The American Journal of Gastroenterology study, Issaka and her colleagues analyzed 2,238 patients ages 50-75 who had received a positive FIT result between April 2012 and February 2015 in the San Francisco Health Network (SFHN).

SFHN includes 11 community- and hospital-based primary care clinics and ZSFG. These clinics share an integrated electronic health record, clinical laboratory and gastroenterology referral unit. The FIT kit is used at home and mailed to the ZSFG laboratory for analysis, with results usually routed to the primary care provider.

SFHN uses an electronic referral platform for all gastroenterology clinic referrals, which a staff gastroenterologist typically evaluates within 72 hours. Patients either attend a clinic appointment or group colonoscopy class, as appropriate, then are consented and scheduled for colonoscopy.

Of the 2,238 total patients analyzed, 1,245 (56 percent) patients completed colonoscopy within a year at an average time of six months (184 days). Women were more likely than men, and married patients more likely than single, separated or divorced patients to complete the procedure. Asian patients had the highest follow-up rate, and non-English speakers were more likely to follow up than English speakers.

Thirteen (13) percent were never referred to the ZSFG gastroenterology group for follow up. Within this group, 49 percent lacked documentation addressing their abnormal result or counseling on the increased risk of prevalent colorectal cancer. Of those patients referred and scheduled, 25 percent missed their appointment, with 62 percent lacking follow-up documentation or counseling. Further, patients with comorbid conditions and illicit substance use were less likely to be referred or make their appointments.

“Despite access to colonoscopy and a shared electronic health record system, colonoscopy completion after an abnormal FIT is inadequate,” said senior author Ma Somsouk, MD, MAS, UCSF Health gastroenterologist and the Dean M. Craig Endowed Chair in Gastrointestinal Medicine. “This issue is attributable to an absence of clear documentation and systematic workflow within both primary care and gastroenterology specialty care. And, at times, patients are too ill to get the benefit of cancer screening but are screened anyways.”

The researchers recommend reporting FIT follow-up rates as a quality measure and organizing tracking and navigation of patients with a high-risk screening result. They also advise developing algorithms to ensure the appropriate patients are being screened, so follow-up occurs for every patient with an abnormal screening test.

“Some private health systems have reported colonoscopy follow-up rates beyond 80 percent,” Issaka said. “Even within this safety net system, there are high-performing clinics with follow-up rates in that vicinity. These clinic- and system-level practices should be identified and shared across health systems.”

Among the study limitations were inabilities to capture out-of-network utilization and medical records occasionally lacking details discussed during patient encounters.

Other UCSF contributors to The American Journal of Gastroenterology study were Maneesh Singh, MD, gastroenterology fellow; Sachiko Oshima, Human Resource Protection Program affiliate; Victoria Laleau, gastroenterology outreach worker; Carly Rachocki, MPH, gastroenterology program manager; Lukejohn Day, MD, associate professor of medicine; and Urmimala Sarkar, MD, MPH, associate professor of medicine. Ellen Chen, MD, of the San Francisco Department of Public Health, also contributed.

Funding was provided by the National Institute of Diabetes, Digestive and Kidney Diseases of the National Institutes of Health T32DK007007, Jacobsohn Fund for Excellence, U.S. Centers for Disease Control and Prevention U48 DP004998, and the Agency for Healthcare Research and Quality 5P30HS023558.

UC San Francisco (UCSF) is a leading university dedicated to promoting health worldwide through advanced biomedical research, graduate-level education in the life sciences and health professions, and excellence in patient care. It includes top-ranked graduate schools of dentistry, medicine, nursing and pharmacy; a graduate division with nationally renowned programs in basic, biomedical, translational and population sciences; and a preeminent biomedical research enterprise. It also includes UCSF Health, which comprises three top-ranked hospitals, UCSF Medical Center and UCSF Benioff Children’s Hospitals in San Francisco and Oakland, and other partner and affiliated hospitals and healthcare providers throughout the Bay Area.