Abstract
Individuals diagnosed with colorectal adenomas with high-risk features during screening colonoscopy have increased risk for the development of subsequent adenomas and colorectal cancer. While US guidelines recommend surveillance colonoscopy at 3 years in this high-risk population, surveillance uptake is suboptimal. To inform future interventions to improve surveillance uptake, we sought to assess surveillance rates and identify facilitators of uptake in a large integrated health system. We utilized a cohort of patients with a diagnosis of ≥ 1 tubular adenoma (TA) with high-risk features (TA ≥ 1 cm, TA with villous features, TA with high-grade dysplasia, or ≥ 3 TA of any size) on colonoscopy between 2013 and 2016. Surveillance colonoscopy completion within 3.5 years of diagnosis of an adenoma with high-risk features was our primary outcome. We evaluated surveillance uptake over time and utilized logistic regression to detect factors associated with completion of surveillance colonoscopy. The final cohort was comprised of 405 patients. 172 (42.5%) patients successfully completed surveillance colonoscopy by 3.5 years. Use of a patient reminder (telephone, electronic message, or letter) for due surveillance (adjusted odds = 1.9; 95%CI = 1.2–2.8) and having ≥ 1 gastroenterology (GI) visit after diagnosis of an adenoma with high-risk features (adjusted odds = 2.6; 95%CI = 1.6–4.2) significantly predicted surveillance colonoscopy completion at 3.5 years. For patients diagnosed with adenomas with high-risk features, surveillance colonoscopy uptake is suboptimal and frequently occurs after the 3-year surveillance recommendation. Patient reminders and visitation with GI after index colonoscopy are associated with timely surveillance completion. Our findings highlight potential health system interventions to increase timely surveillance uptake for patients diagnosed with adenomas with high-risk features.
Highlights
Individuals diagnosed with colorectal adenomas with high-risk features during screening colonoscopy have increased risk for the development of subsequent adenomas and colorectal cancer
We found that uptake of surveillance colonoscopy often occurred after the 3-year surveillance interval and remained low 4 years after high-risk adenoma (HRA) diagnosis in a large and integrated academic health network
We demonstrated that patients who saw GI in consultation at least once or who received an electronic, telephone, or mailed reminder that surveillance was due were more likely to complete surveillance in a timely manner
Summary
Individuals diagnosed with colorectal adenomas with high-risk features during screening colonoscopy have increased risk for the development of subsequent adenomas and colorectal cancer. Our findings highlight potential health system interventions to increase timely surveillance uptake for patients diagnosed with adenomas with high-risk features. In a large retrospective cohort within community practice, only 30.7% of patients diagnosed with advanced tubular adenoma (aTA; defined by having at least one TA ≥ 1 cm, TA with tubulovillous/ villous histology, or TA with high-grade dysplasia) and 19.5% of patients with 3 or more non-advanced adenomas completed surveillance by 3 years[8]. Ample efforts in public health and clinical research address suboptimal CRC screening rates and evaluate interventions to increase screening among individuals at average-risk for CRC; strategies to reduce ongoing risk following diagnosis of an adenoma with highrisk features remain sparse in CRC prevention and control[10]. Non-modifiable predictors for timely surveillance including younger age, having a first-degree relative with CRC, and having ≥ 3 a denomas[8,9,11], but less is known about modifiable patient-, provider-, and health-system factors that could serve as potential targets for interventions to increase timely surveillance uptake
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