Factors Associated With Timely Colonoscopy Completion After an Abnormal FIT in a Safety-Net System

Abstract

Introduction: The effectiveness of colorectal cancer (CRC) screening is dependent on timely completion of diagnostic colonoscopy in patients with abnormal fecal immunochemical test (FIT). We examined the characteristics of a FIT positive population to determine the factors associated with timely colonoscopy completion in a FIT based safety-net system. Methods: We performed a retrospective cohort study of patients aged 50-75 who were members of 11 community health centers with an abnormal FIT between January 1, 2011 and April 1, 2014. Direct access referral for colonoscopy had been available since 2009. The primary outcome was completion of colonoscopy within 1-year from date of positive FIT. We calculated time-to-colonoscopy after abnormal FIT for each of the safety-net clinics. Univariate and multivariate logistic regression identified predictors of colonoscopy completion within 1year of abnormal FIT. Results: Of the1881 patients identified with an abnormal FIT, 1,169 (62.1%) completed a diagnostic colonoscopy. 989 (52.6%) within the 1st year, 180 (9.5%) within the 2nd year, and 712 (37.9%) never completed a colonoscopy. The median age was 60, 52% were male, and they were racially diverse (39% Asian, 22% White, 18% Black, and 18% Hispanic). 54% identified English as their primary language and 36% were married. In univariate analysis, female gender (57% vs. 48%, P < 0.01) and being married (61% vs. 49%, P < 0.01) were associated with higher colonoscopy completion. 60.6% of Asian patients completed colonoscopies compared to 48.7% whites and 41.6% blacks (P < 0.01). Each additional year in age was associated with a 2.2% decreased odds of colonoscopy completion (OR 0.98, 95% CI 0.97 - 0.99, P < 0.01). Two outlier clinics, with dedicated medical assistants performing FIT-based panel management had significantly higher colonoscopy completion rates. Within these two clinics, all races demonstrated colonoscopy completion rates of 70% at one-year vs. mean of 50% at the other clinics (P < 0.01). Conclusion: Out-of-network services in patients >65 years who qualify for Medicare may occur but is likely limited. Diagnostic colonoscopy was completed in only 53% of patients with an abnormal FIT after one year in our safety-net system. Asian race, being married, and assignment to high performing clinics were associated with timely completion of colonoscopy after an abnormal FIT. In addition to social and financial barriers, in depth analysis of clinic specific practices is warranted.