Disappointing Referral Rates for Colorectal Cancer (CRC) Screening Despite Open Access Colonoscopy

Abstract

Purpose: To assess referral rates for colonoscopic screening for colorectal cancer (CRC) for eligible veterans 3 years after institution of an open access program in our VA Hospital. Methods: 2058 patients were seen by 10 primary care providers from Jan 1st 2008 to March 31st 2008. Patients were deemed to be eligible if they were 50-80 years old and did not have any documented evidence of endoscopic screening within 10 years. Referral rates for colonoscopic screening were recorded along with rates of colonoscopy completion. Rates of completion of FOBT testing and patient refusal of screening were also recorded. Results: Of the 2058 patients seen, 283 (13.7%) were eligible for screening. Number of patients referred for colonoscopy was 27 (9.54%). Number of patients completing colonoscopy 16 (5.65%). The number of patients returning the FOBT kits was 111 (39%). Number of patients refusing colonoscopy was 140 (49%). Number of eligible patients not referred 116 (41%). Of the 27 colonoscopy referrals, 11 (40%) resulted from positive FOBTs. Conclusion: Screening rates for CRC remain dismal in spite of an institution-wide policy of open access colonoscopy in place for 2 years. Limiting factors may include, among others, poor patient acceptance or knowledge defects, associated medical conditions, limited access to endoscopic screening, and primary care encounters that do not emphasize screening. Many patients are provided FOBT screening despite availability of colonoscopy. Exclusively increasing the capacity to perform colonoscopy may be insufficient to increase rates of screening. One possible intervention would be to increase patient awareness of individual risk for CRC which could be performed by validated risk assessment tools available online. We hypothesize that the multitude of objectives at brief primary care encounters precludes appropriate presentation of screening options. Also, providers and patients may be insufficiently motivated by underestimations of patient risks of CRC.Figure: CRC screening outcomes for eligible veterans.Table: Screening results for veterans from Jan 2008-March 2008