Abstract
The effectiveness of stool-based colorectal cancer (CRC) screening, including fecal immunochemical tests (FITs), relies on colonoscopy completion among patients with abnormal results, but in safety net systems and federally qualified health centers, in which FIT is frequently used, colonoscopy completion within 1 year of an abnormal result rarely exceeds 50%. Clinician-identified factors in follow-up of abnormal FIT results are understudied and could lead to more effective interventions to address this issue. To describe clinician-identified barriers and facilitators to colonoscopy completion among patients with abnormal FIT results in a safety net health care system. This qualitative study was conducted using semistructured key informant interviews with primary care physicians (PCPs) and staff members in a large safety net health care system in Washington state. Eligible clinicians were recruited through all-staff meetings and clinic medical directors. Interviews were conducted from February to December 2020 through face-to-face interactions or digital meeting platforms. Interview transcripts were analyzed deductively and inductively using a content analysis approach. Data were analyzed from September through December 2020. Barriers and facilitators to colonoscopy completion after an abnormal FIT result were identified by PCPs and staff members. Among 21 participants, there were 10 PCPs and 11 staff members; 20 participants provided demographic information. The median (interquartile range) age was 38.5 (33.0-51.5) years, 17 (85.0%) were women, and 9 participants (45.0%) spent more than 75% of their working time engaging in patient care. All participants identified social determinants of health, organizational factors, and patient cognitive factors as barriers to colonoscopy completion. Participants suggested that existing resources that addressed these factors facilitated colonoscopy completion but were insufficient to meet national follow-up colonoscopy goals. In this qualitative study, responses of interviewed PCPs and staff members suggested that the barriers to colonoscopy completion in a safety net health system may be modifiable. These findings suggest that interventions to improve follow-up of abnormal FIT results should be informed by clinician-identified factors to address multilevel challenges to colonoscopy completion.
Highlights
There is clear evidence that screening for colorectal cancer (CRC) by stool-based tests is cost-effective[1] and saves lives[2]; screening remains underused, especially among members of racial/ethnic minority groups and low-income populations.[3]
In this qualitative study, responses of interviewed primary care physicians (PCPs) and staff members suggested that the barriers to colonoscopy completion in a safety net health system may be modifiable
These findings suggest that interventions to improve follow-up of abnormal fecal immunochemical test (FIT) results should be informed by clinician-identified factors to address multilevel challenges to colonoscopy completion
Summary
There is clear evidence that screening for colorectal cancer (CRC) by stool-based tests is cost-effective[1] and saves lives[2]; screening remains underused, especially among members of racial/ethnic minority groups and low-income populations.[3] In safety net health care settings and federally qualified health centers (FQHCs) (eTable in the Supplement), in which many medically underserved populations receive care, CRC screening improves when a fecal immunochemical test (FIT) is offered alongside colonoscopy.[4] owing to patient preference and limited resources,[5] FIT has become a cornerstone for CRC screening in these settings. At Harborview Medical Center (HMC), a safety net health care system for the Seattle region, among 299 adults ages 50 to 75 with an abnormal FIT result for CRC screening from 2014 to 2018, 122 individuals (40.8%), completed a colonoscopy within 1 year of their abnormal result (patient electronic health record [EHR] data obtained by R.B.I. from University of Washington Medicine Information Technology Services on November 20, 2019). While these results are promising, they suggest the need for additional interventions to achieve the US Multi-Society Task Force (USMSTF) follow-up colonoscopy goal of 80%
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