Abstract C80: Colonoscopy follow up after abnormal colorectal cancer screening tests at a large Federally Qualified Community Health Center

Abstract

Abstract Background. Screening for colorectal cancer (CRC) can reduce cancer incidence and mortality, but participation rates are low among underserved populations. Federally Qualified Health Centers (FQHCs) in many states have an opportunity to be at the vanguard of improving screening rates among underserved populations, due to new acquisition of Medicaid insurance by patients. Many FQHCs are employing non-invasive strategies, such as the fecal immunochemical test (FIT), to increase screening rates. Non-invasive tests such as the FIT are generally inexpensive, convenient, and often acceptable for patients. However, effectiveness of non-invasive screening in prevention or early detection of CRC depends heavily on ability to ensure diagnostic colonoscopy after abnormal screening tests. Specifically, prevention and early detection benefits of identifying patients through non-invasive screening at increased risk for CRC and polyps can only be realized if rates of diagnostic colonoscopy after positive tests are high. Indeed, up to 1 in 33 patients with an abnormal FIT have CRC. As part of a community-academic partnership between Family Health Centers of San Diego (FHCSD), San Diego State University, and UC San Diego Moores Cancer Center, we aimed to characterize CRC screening processes, including rates of complete diagnostic follow up after abnormal FIT testing. Methods. FHCSD is a large FQHC serving 134,788 patients annually through 19 community clinics. The patient population is largely Latino (55%); 97% live at or below 200% of poverty, with most patients having less than a high school education. Following the Quality of Cancer Care Continuum principles adapted by Tiro et al.1 for CRC screening, we mapped the CRC screening process at FHCSD, and characterized drop-offs at various steps in the screening process by querying the electronic health record to identify all individuals with FIT orders over a six-month period (10/01/15 - 03/31/16). Outcomes of interest included rates of FIT completion, abnormal test results, and colonoscopy orders and completion among patients with an abnormal FIT, characterized via descriptive statistics. Results. Over a six-month period, across 19 clinics within FHCSD, 9,378 FITs were ordered. Patients returned 25% of FITs ordered (2327/9378). Among returned FITs, 7% were abnormal (156/2327). Among patients with an abnormal FIT 85% (132/156) had orders for referral colonoscopy, and 21% had documented evidence of colonoscopy completion (33/156). FIT return was statistically significantly higher for patients without (33%; 368/1119) vs. with insurance (24%; 1959/8259; p comparison = <0.001). However, diagnostic colonoscopy completion after abnormal FIT was higher for patients with (24%; 31/132) vs. without insurance (8%; 2/24), though the difference was not statically significant. Conclusions.Low rates of diagnostic colonoscopy after abnormal non-invasive CRC screening tests may adversely impact effectiveness of CRC screening programs. Research should focus on understanding reasons for fall offs in the screening process, and developing multilevel interventions to optimize follow up, particularly given the expanding array of non-invasive CRC screening tests being made available in usual practice. Conducting these studies in FQHC settings is critical, since increases in screening in these settings may largely occur as a result of implementation and promotion of non-invasive tests.