Abnormal Fecal Immunochemical Test Research Articles

Electronic coding for abnormal fecal immunochemical test is associated with increased colonoscopy completion.

Electronic coding for abnormal fecal immunochemical test is associated with increased colonoscopy completion.

Methods for scaling up an outreach intervention to increase colorectal cancer screening rates in rural areas

BackgroundMailed fecal immunochemical test (FIT) outreach and patient navigation are evidence-based practices shown to improve rates of colorectal cancer (CRC) and follow-up in various settings, yet these programs have not been broadly adopted by health systems and organizations that serve diverse populations. Reasons for low adoption rates are multifactorial, and little research explores approaches for scaling up a complex, multi-level CRC screening outreach intervention to advance equity in rural settings.MethodsSMARTER CRC, a National Cancer Institute Cancer Moonshot project, is a cluster-randomized controlled trial of a mailed FIT and patient navigation program involving 3 Medicaid health plans and 28 rural primary care practices in Oregon and Idaho followed by a national scale-up trial. The SMARTER CRC intervention combines mailed FIT outreach supported by clinics, health plans, and vendors and patient navigation for colonoscopy following an abnormal FIT result. We applied the framework from Perez and colleagues to identify the intervention’s components (including functions and forms) and scale-up dissemination strategies and worked with a national advisory board to support scale-up to additional organizations. The team is recruiting health plans, primary care clinics, and regional and national organizations in the USA that serve a rural population. To teach organizations about the intervention, activities include Extension for Community Healthcare Outcomes (ECHO) tele-mentoring learning collaboratives, a facilitation guide and other materials, a patient navigation workshop, webinars, and individualized technical assistance. Our primary outcome is program adoption (by component), measured 6 months after participation in an ECHO learning collaborative. We also assess engagement and adaptations (implemented and desired) to learn how the multicomponent intervention might be modified to best support broad scale-up.DiscussionFindings may inform approaches for adapting and scaling evidence-based approaches to promote CRC screening participation in underserved populations and settings.Trial registrationRegistered at ClinicalTrials.gov (NCT04890054) and at the NCI’s Clinical Trials Reporting Program (CTRP no.: NCI-2021–01032) on May 11, 2021.

Implementing an Organized Colorectal Cancer Screening Program: Lessons Learned From an Academic–Community Practice

IntroductionThe effectiveness of mailed fecal immunochemical test (FIT) outreach might be enhanced through an organized colorectal cancer (CRC) screening program, yet published real-world experiences are limited. We synthesized the process of implementing a CRC screening program which used mailed FIT outreach in a large integrated academic-community practice. Materials and MethodsData from a pilot mailed FIT program were shared with healthcare system leadership which inspired the creation of a cross-institutional organized CRC Screening Program. In partnership with a centralized Population Health Team and Primary Care, we defined: 1) the institutional approach to CRC screening, 2) the target population and method for screening, 3) the team responsible for implementation, 4) the healthcare team responsible for decisions and care, 5) a quality assurance structure, and 6) a method for identifying cancer occurrence. ResultsThe Fred Hutch/UW Medicine Population Health CRC Screening Program began in September 2021. The workflow for mailed FIT outreach included a mailed postcard, a MyChart message from the patient's primary care provider (PCP), a FIT kit with a letter signed by the PCP and program director, and up to three bi-weekly reminders. Patients without a colonoscopy 3 months after an abnormal FIT result received navigation through the program. In the first program year, we identified 9,719 patients eligible for outreach and in an intention to treat analysis, 32% of patients completed CRC screening by FIT or colonoscopy. ConclusionsReal-world experiences detailing how to implement organized CRC screening programs might increase adoption. In our experience, broadly disseminating pilot data, early institutional support, robust data management and strong cross-departmental relationships were critical to successfully implementing a CRC screening program that benefits all patients.

Abnormal Colorectal Cancer Test Follow-Up: A Quality Improvement Initiative at a Federally Qualified Health Center.

Colonoscopy completion rates after an abnormal fecal immunochemical test (FIT) are suboptimal, resulting in missed opportunities for early detection and prevention of colorectal cancer. Patient navigation and structured follow-up may improve colonoscopy completion, but implementation of these strategies is not widespread. We conducted a quality improvement study using a Plan-Do-Study-Act (PDSA) Model to increase colonoscopy completion after abnormal FIT in a large federally qualified health center serving a diverse and low-income population. Intervention components included patient navigation, and a checklist to promote completion of key steps required for abnormal FIT follow-up. Primary outcome was proportion of patients achieving colonoscopy completion within 6 months of abnormal FIT, assessed at baseline for 156 patients pre-intervention, and compared to 208 patients during the intervention period from April 2017 to December 2019. Drop offs at each step in the follow-up process were assessed. Colonoscopy completion improved from 21% among 156 patients with abnormal FIT pre-intervention, to 38% among 208 patients with abnormal FIT during the intervention (P < .001; absolute increase: 17%, 95% CI: 6.9%-25.2%). Among the 130 non-completers during the intervention period, lack of completion was attributable to absence of colonoscopy referral for 7.7%; inability to schedule a pre-colonoscopy specialist visit for 71.5%; failure to complete a pre-colonoscopy visit for 2.3%; the absence of colonoscopy scheduling for 9.2%; failure to show for a scheduled colonoscopy for 9.2%. Patient navigation and structured follow-up appear to improve colonoscopy completion after abnormal FIT. Additional strategies are needed to achieve optimal rates of completion.

Developing Patient-Refined Messaging for Follow-Up Colonoscopy After Abnormal Fecal Testing in Hispanic Communities: Key Learnings from Virtual Boot Camp Translation

Colorectal cancer (CRC) is a leading cause of cancer death in the US. Screening by fecal immunochemical test (FIT) is a strategy to lower CRC rates. Unfortunately, only half of patients with an abnormal FIT result complete the follow-up colonoscopy, an essential component of screening. We used virtual Boot Camp Translation (BCT), to elicit input from partners to develop messaging/materials to motivate patients to complete a follow-up colonoscopy. Participants were Hispanic, ages 50 to 75 years, and Spanish-speaking. All materials were developed in English and Spanish. The first meeting included expert presentations that addressed colorectal health. The two follow-up sessions obtained feedback on messaging/materials developed based on themes from the first meeting. Ten participants attended the first meeting and eight attended the follow-up sessions. The two key barriers to follow-up colonoscopy after abnormal FIT noted by participants were (a) lack of colonoscopy awareness and (b) fear of the colonoscopy procedure. We learned that participants valued simple messaging to increase knowledge and alleviate concerns, patient-friendly outreach materials, and increased access to health information. Using virtual BCT, we included participant feedback to design culturally relevant health messages to promote follow-up colonoscopy after abnormal fecal testing among Hispanic patients served by community clinics.

S403 Colon Cancer Surveillance Recommendations After Abnormal Fecal Immunochemical Test and Normal Colonoscopy: Results From the Veterans Administration Population Data

S403 Colon Cancer Surveillance Recommendations After Abnormal Fecal Immunochemical Test and Normal Colonoscopy: Results From the Veterans Administration Population Data

S388 Patient Navigation Increases Follow-Up After Abnormal Fecal Immunochemical Test Results but Reveals Persistent Barriers to Colonoscopy

S388 Patient Navigation Increases Follow-Up After Abnormal Fecal Immunochemical Test Results but Reveals Persistent Barriers to Colonoscopy

Performance of OC-Auto Micro 80 Fecal Immunochemical Test in an Integrated Academic-Community Health System.

We aimed to determine the performance of the OC-Auto Micro 80 fecal immunochemical test (FIT) in an average-risk population receiving care in an integrated, academic-community health system. The FIT is the most used colorectal cancer (CRC) screening test worldwide. However, many Food and Drug Administration-cleared FIT products have not been evaluated in clinical settings. We performed a retrospective cohort study of patients (50 to 75y old) in the University of Washington Medicine health care system who were screened for CRC by OC-Auto Micro 80 FIT between March 2016 and September 2021. We used electronic health records to extract patient-level and clinic-level factors, FIT use, colonoscopy, and pathology findings. The primary outcomes were the FIT positivity rate and neoplasms detected at colonoscopy. Secondary outcomes were FIT positivity by sex and safety-net versus non-safety-net clinical settings. We identified 39,984 FITs completed by 26,384 patients; 2411 (6.0%) had a positive FIT result (>100 ng/mL of hemoglobin in buffer), and 1246 (51.7%) completed a follow-up colonoscopy. The FIT positive rate was 7.0% in men and 5.2% in women (P <0.01). Among those who completed a colonoscopy after an abnormal FIT result, the positive predictive value for CRC, advanced adenoma, and advanced neoplasia was 3.0%, 20.9%, and 23.9%, respectively. In a retrospective analysis of a large heterogeneous population, the OC-Auto Micro 80 FIT for CRC screening demonstrated a positivity rate of 6.0% and a positive predictive value for CRC of 3.0%.

Reach and effectiveness of a centralized navigation program for patients with positive fecal immunochemical tests requiring follow-up colonoscopy

Completion rates for follow-up colonoscopies after an abnormal fecal immunochemical test (FIT) are suboptimal in federally qualified health center (FQHC) settings. We implemented a screening intervention that included mailed FIT outreach to North Carolina FQHC patients from June 2020 to September 2021 and centralized patient navigation to support patients with abnormal FITs in completing follow-up colonoscopy. We evaluated the reach and effectiveness of navigation using electronic medical record data and navigator call logs detailing interactions with patients. Reach assessments included the proportion of patients successfully contacted by phone and who agreed to participate in navigation, intensity of navigation provided (including types of barriers to colonoscopy identified and total navigation time), and differences in these measures by socio-demographic characteristics. Effectiveness outcomes included colonoscopy completion, timeliness of follow-up colonoscopy (i.e., within 9 months), and bowel prep adequacy. Among 514 patients who completed a mailed FIT, 38 patients had an abnormal result and were eligible for navigation. Of these, 26 (68%) accepted navigation, 7 (18%) declined, and 5 (13%) could not be contacted. Among navigated patients, 81% had informational needs, 38% had emotional barriers, 35% had financial barriers, 12% had transportation barriers, and 42% had multiple barriers to colonoscopy. Median navigation time was 48.5 min (range: 24–277 min). Colonoscopy completion differed across groups – 92% of those accepting navigation completed colonoscopy within 9 months, versus 43% for those declining navigation. We found that centralized navigation was widely accepted in FQHC patients with abnormal FIT, and was an effective strategy, resulting in high colonoscopy completion rates.

A75 COLONOSCOPY COLORECTAL CANCER DETECTION - HOW DOES IT VARY BY INDICATION, SETTING AND PATIENT DEMOGRAPHIC?

Abstract Background Because of limited access to gastrointestinal (GI) endoscopy during the COVID-19 pandemic, there is a need to prioritize procedures to avoid negative health impacts from delays. Ontario Health (OH) has provided guidance to facilities to prioritize colonoscopies in people with an abnormal fecal immunochemical test (FIT) result, based on the high likelihood to detect invasive colorectal cancer (CRC) and recommends FIT for screening people at average risk of CRC and those with prior low-risk adenoma. Purpose To measure the invasive CRC detection rate (CDR) of colonoscopies performed in Ontario by indication, setting, age, and sex over a 31-month period before and during the COVID-19 pandemic. Method We calculated the CDRs among outpatients ages 18 and over who had colonoscopies performed in a hospital or private clinic setting from June 2019 to December 2021. We identified hospital colonoscopies from OH’s GI Endoscopy Data Submission Portal and clinic colonoscopies from Ontario Health Insurance Plan (OHIP) data (OHIP code E749A). Invasive CRC was identified from the Ontario Cancer Registry (OCR) as: ICD-O-3 codes C18.0, C18.2-C18.9, C19.9, C20.9, a morphology indicative of CRC, microscopically confirmed and with a pathology report. CRCs were included if diagnosed 7 days before and up to 183 days after colonoscopy. Colonoscopy volumes and CDRs were stratified by age and sex (all volumes), and, for hospital colonoscopies, by indication. Result(s) During the study period, 984,109 colonoscopies were performed (638,900 in hospitals; 345,209 in clinics). Patients who had their colonoscopies in clinics were younger than those who had them in hospitals (Table 1). In both settings, colonoscopies were evenly distributed by sex. Overall, 12,021 CRCs were detected (CDR: 1.22%); 9,451 CRCs in hospitals (CDR: 1.48%), and 2,570 CRCs in clinics (CDR: 0.74%). CDRs at any age were lower in clinics as compared to hospitals. In hospitals, CDRs by colonoscopy indication were: 5.16% for FIT+, 1.93% in symptomatic patients, 0.52% in surveillance, 0.70% in average-risk screening, and 0.35% in screening due to family history. FIT+ colonoscopies accounted for the smallest proportion of colonoscopies (6.2%) but the 2nd largest proportion of CRCs detected (Figure 1). Hospital-based CDR increased during the period of observation from 1.23% pre-pandemic (June-December 2019) to 1.55% during the pandemic (January-December 2021). Clinic CDR was 0.71% pre-pandemic and 0.75% during the pandemic. Image Conclusion(s) In Ontario, colonoscopy yield (CDR) is highest in FIT+ patients; just over one in 20 colonoscopies will yield a diagnosis of CRC. In contrast, primary screening and surveillance indications have very low CRC yields. The overall yield of colonoscopies in clinics, for all age groups, is lower than in hospital setting. There was a slight increase in CDR during the pandemic compared to before the pandemic, in both settings. Please acknowledge all funding agencies by checking the applicable boxes below Other Please indicate your source of funding; Ontario Health - Cancer Care Ontario Disclosure of Interest None Declared

Data Challenges in Identifying Patients Due for Colorectal Cancer Screening in Rural Clinics

Colorectal cancer (CRC) incidence and mortality are disproportionately high among rural residents despite the availability of effective screening methods. Outreach activities can improve CRC screening rates but rely on accurate identification of patients due for screening. We report on data challenges in rural clinics and Medicaid health plans in Oregon in identifying patients eligible for CRC screening, in a large project implementing mailed fecal immunochemical tests (FIT) and patient navigation. We analyzed data from clinic intake surveys and administrative claims. Clinics were asked to identify total population numbers relevant to CRC screening and follow-up. Health plans also identified enrollees eligible for CRC screening in Spring, 2021. Clinic staff validated patient lists for eligibility using their electronic health records (EHR). EHR features varied across the 29 participating and 28 responding clinics. Among the 28 responding clinics, 21 were able to report their Medicaid population (75%), 19 reported the number of patients aged 50 to 75 (68%) and the number screened for CRC in the last year (68%). Only 8 (29%) were able to report screening details such as number screened by FIT and 9 were able to report on patients with an abnormal FIT or colonoscopy completed after FIT (32%). Health plans had challenges properly identifying where enrollees received care and had missing data for race and ethnicity (range 22 to 34% unknown race, <1% to 24% unknown ethnicity). Most participating rural primary care clinics and Medicaid health plans experienced challenges identifying the population due for a CRC screening outreach program. Better EHR functionality and data reporting capabilities could help rural clinics apply population-based strategies and ultimately attenuate disparities in cancer screening and follow-up.

Abstract A019: Impact of COVID-19 on patient navigation services for follow-up colonoscopy after abnormal fecal testing in community health centers

Abstract Introductory sentence about purpose of the study: The PRECISE study tests the effectiveness of a targeted patient navigation program for follow-up colonoscopy after abnormal fecal testing in community health centers. We present adaptations of the patient navigation program resulting from the impact of the COVID-19 pandemic. Brief description of pertinent experimental procedures: Colorectal cancer (CRC) screening by annual fecal immunochemical test (FIT) is an accessible and cost-effective strategy to lower CRC incidence and mortality. However, this mode of screening depends on follow-up colonoscopy after an abnormal FIT result to prevent CRC or find it in early, treatable forms. Unfortunately, almost half of patients with an abnormal FIT result fail to complete this essential screening component. Patient navigation can provide needed support for patients to complete a follow-up colonoscopy. PRECISE is a collaboration with a large community health center whose patient population is 37% Latino. Eligible patients were aged 50-75, had an abnormal FIT result in the past month, and were due for a follow-up colonoscopy. Patients were randomized to patient navigation or usual care. Patient navigation was delivered by a bilingual (English and Spanish) patient navigator using a six-topic phone-based protocol, adapted from the New Hampshire Colorectal Cancer Screening Program. Summary of new, unpublished data: A total of 985 patients were enrolled in the PRECISE study, 489 randomized to the intervention arm and 496 to the control arm. Due to the COVID-19 pandemic, we made adaptations to the navigator training program and navigation delivery. We converted our in-person training program to a virtual navigation training series combining pre-recorded videos and live webinars. Additionally, we strengthened relationships with GI practices to expedite referrals, improve scheduling processes, and better understand COVID-related policy changes including the conversion of some pre-procedure consultations to a phone-based platform and COVID-19 testing requirements prior to the colonoscopy. Finally, we adapted patient navigator messages to address fear and anxiety about getting medical care during the peak COVID-19 pandemic. Preliminary patient navigation outcomes will be available in September 2022. Statement of conclusions: This innovative clinical trial highlights the importance of patient navigation to improve CRC screening in community health centers. Rapid response to COVID-19 provided the opportunity to adapt our navigator program for a virtual setting allowing for 1) the sustainability of patient navigation during the pandemic and 2) the broadening of training resources for patient navigators and community health workers. Citation Format: Jamie H. Thompson, Jennifer Rivelli, Jennifer Schneider, Amanda F. Petrik, Gloria D. Coronado. Impact of COVID-19 on patient navigation services for follow-up colonoscopy after abnormal fecal testing in community health centers [abstract]. In: Proceedings of the AACR Special Conference on Colorectal Cancer; 2022 Oct 1-4; Portland, OR. Philadelphia (PA): AACR; Cancer Res 2022;82(23 Suppl_1):Abstract nr A019.

S252 Screening With FIT-DNA: Impact on Colonoscopy Withdrawal Time, Adenoma Detection and Endoscopist’s Recommendation for Follow-Up

Introduction: Limited data exist on colonoscopy after abnormal fecal immunochemical test (FIT)-DNA (a.k.a. multitarget stool DNA test). We hypothesized that endoscopists perform a more careful exam (e.g., longer withdrawal time (WT)) and recommend early re-screening after FIT-DNA+/negative colonoscopy due to expectations about test performance. We aimed to A) determine adenoma detection rate (ADR) and other lesion detection rates and B) assess endoscopist behavior regarding WT and recommendations after negative colonoscopy for 3 indications: 1) FIT-DNA+, 2) average-risk screening (SCR) and 3) abnormal fecal occult blood test (FOBT+, guaiac or FIT). Methods: Using GIQuIC data (2019-2022) from 727 endoscopy units, we identified patients aged 50-75 years undergoing colonoscopy for FIT-DNA+, SCR or FOBT+. We excluded colonoscopy with any other indications (e.g., family history), inadequate bowel preparation or incomplete exam. If pathology was obtained but results were not available, the record was excluded from pathology-related outcomes. Generalized estimating equations clustered by endoscopist were used to assess the association between indication and outcomes while adjusting for patient characteristics and endoscopist's screening ADR. Results: >1.8 million colonoscopies were included; demographics varied by indication (Table). FIT-DNA+ was associated with higher ADR (59.6%) than SCR (39.3%, p< 0.0001) and FOBT+ (53.8%, p< .0001) and greater detection of advanced neoplasia and sessile serrated lesions (Table). Among those with no pathology obtained on colonoscopy, WT was longer for FIT-DNA+ than for SCR and FOBT+. Among patients aged 50-65 years with no pathology and ASA < IV, a 10-year colonoscopy was recommended in only 80.1% of FIT-DNA+ patients vs. 87.2% of SCR and 86.5% of FOBT+. In multivariable models, compared to FIT-DNA+, SCR and FOBT+ are associated with shorter WT (p< 0.0001 for both), and lower odds of adenoma detection (OR 0.48 (95% CI 0.47-0.50) and 0.71 (0.68-0.74), respectively) and recommendations for re-screening in < 10 years (OR 0.64 (0.57-0.72) and 0.84 (0.74-0.96), respectively). Conclusion: FIT-DNA+ is associated with greater neoplasia detection than FOBT+ and SCR, but also with longer WT and more recommendations for early re-screening after a negative colonoscopy. Despite lower specificity of FIT-DNA vs. FOBT, endoscopists seem to have greater concern for missed pathology in FIT-DNA+/negative colonoscopies, leading to downstream impacts on healthcare utilization. Table 1. - Colonoscopy for Abnormal FIT-DNA vs. Average Risk Screening vs. Abnormal FOBT:Patient Characteristics, Findings and Follow-Up Recommendations After a Negative Exam FIT-DNA+(n=23,046) Average Risk Screening(n=1,760,840) FOBT+(n=26,455) Age, mean (sd) 64.2 (7.1) 58.7 (7.2) 63.8 (7.2) Male (%)Female (%) 9,939 (43.1)13,107 (56.9) 816,630 (46.4)944,210 (53.6) 12,698 (48.0)13,757 (52.0) White (%)Black of African American (%)Asian (%)Other (%)Unknown/Declined (%) 15,777 (68.5)1085 (4.7)211 (0.9)514 (2.2)5459 (23.7) 1,022,859 (58.1)171,348 (9.7)56,644 (3.2)68,966 (3.9)441,033 (25.1) 16,387 (61.9)2112 (8.0)959 (3.6)1224 (4.6)5773 (21.8) Non-Hispanic (%)Hispanic/Latino (%)Unknown/Decline 14,234 (61.8)560 (2.4)8252 (35.8) 1,018,724 (57.9)107,147 (6.1)634,969 (36.1) 16,691 (63.1)2407 (9.1)7357 (27.8) Total endoscopists contributing colonoscopies 2650 4845 3223 Endoscopist mean ADR‡(sd) with minimum 50 colonoscopies 39.1% (10.2)(Endoscopist n=2467) 39.2% (10.9)(Endoscopist n=3878) 39.5% (10.6)(Endoscopist n=3006) Colonoscopy Findings Adenoma Detection Rate (ADR) 59.6% *,§ 39.3% § 53.8% ADR for Males 67.6% *,§ 46.4% § 61.0% ADR for Females 53.6% *,§ 33.2% § 47.2% Advanced Neoplasia Detection± 22.2% *,§ 7.6% § 17.4% Sessile Serrated Lesion Detection 16.2% *,§ 8.2% † 8.8% Adenocarcinoma Detection 1.5% * 0.3% § 1.4% Analysis of Subgroup with No Polyps on Colonoscopy (i.e., No Pathology Obtained) Median Withdrawal Time, Minutes (interquartile range) (n=4211)8.5 (6.9-11.0) *,§ (n=673,519)7.8 (6.4-9.9) (n=7455)7.8 (6.3-10.1) Next Recommended Colonoscopy (limited to age 50-65, ASA< IV, exclude other or none)< 10 Years (%)10 Years (%) (n=2125)422 (19.9)1703 (80.1) (n=567,568)72,403 (12.8)495,165 (87.2) (n=4301)579 (13.5)3722 (86.5) Next Recommended Colonoscopy (limited to age 50-65, ASA< IV, exclude other or none)≤3 Years (%)4 or 5 Years (%)6-9 Years (%)10 Years (%)Excluded intervals n:OtherNone (n=2125)*,§ 76 (3.6)333 (15.7)13 (0.6)1703 (80.1) 1518 (n=567,568)§ 3840 (0.7)65,289 (11.5)3274 (0.6)495,165 (87.2) 2335974 (n=4301)65 (1.5)478 (11.1)36 (0.8)3722 (86.5) 2919 ‡ADR includes average risk screening only, ages 50-75, photodocumentation of the cecum, adequate bowel preparation.*p<0.0001 compared with average risk screening.§p<0.0001 compared with FOBT+.†p=0.0002 compared with FOBT+. ± Includes either 1) adenoma≥10 mm, with high grade dysplasia, or with villous component; OR 2) sessile serrated polyp (SSP)≥10 mm, SSP with dysplasia, or traditional serrated adenoma; OR 3) adenocarcinoma.

Improving colorectal cancer screening in rural primary care: Preliminary effectiveness and implementation of a collaborative mailed fecal immunochemical test pilot.

Mailed fecal immunochemical test (FIT) outreach can improve colorectal cancer (CRC) screening rates. We piloted a collaborative mailed FIT program with health plans and rural clinics to evaluate preliminary effectiveness and refine implementation strategies. We conducted a single-arm study using a convergent, parallel mixed-methods design to evaluate the implementation of a collaborative mailed FIT program. Enrollees were identified using health plan claims and confirmed via clinic scrub. The intervention included a vendor-delivered automated phone call (auto-call) prompt, FIT mailing, and reminder auto-call; clinics were encouraged to make live reminder calls. Practice facilitation was the primary implementation strategy. At 12 months post mailing, we assessed the rates of: (1) mailed FIT return and (2) completion of any CRC screening. We took fieldnotes and conducted postintervention key informant interviews to assess implementation outcomes (eg, feasibility, acceptability, and adaptations). One hundred and sixty-nine Medicaid or Medicare enrollees were mailed a FIT. Over the 12-month intervention, 62 participants (37%) completed screening of which 21% completed the mailed FIT (most were returned within 3 months), and 15% screened by other methods (FITs distributed in-clinic, colonoscopy). Enrollee demographics and the reminder call may encourage mailed FIT completion. Program feasibility and acceptability was high and supported by perceived positive benefit, alignment with existing workflows, adequate staffing, and practice facilitation. Collaborative health plan-clinic mailed FIT programs are feasible and acceptable for implementation in rural clinics and support CRC screening completion. Studies that pragmatically test collaborative approaches to mailed FIT and patient navigation follow-up after abnormal FIT and support broad scale-up in rural settings are needed.

Extent of Follow-Up on Abnormal Cancer Screening in Multiple California Public Hospital Systems: A Retrospective Review

BackgroundInequitable follow-up of abnormal cancer screening tests may contribute to racial/ethnic disparities in colon and breast cancer outcomes. However, few multi-site studies have examined follow-up of abnormal cancer screening tests and it is unknown if racial/ethnic disparities exist.ObjectiveThis report describes patterns of performance on follow-up of abnormal colon and breast cancer screening tests and explores the extent to which racial/ethnic disparities exist in public hospital systems.DesignWe conducted a retrospective cohort study using data from five California public hospital systems. We used multivariable robust Poisson regression analyses to examine whether patient-level factors or site predicted receipt of follow-up test.Main MeasuresUsing data from five public hospital systems between July 2015 and June 2017, we assessed follow-up of two screening results: (1) colonoscopy after positive fecal immunochemical tests (FIT) and (2) tissue biopsy within 21 days after a BIRADS 4/5 mammogram.Key ResultsOf 4132 abnormal FITs, 1736 (42%) received a follow-up colonoscopy. Older age, Medicaid insurance, lack of insurance, English language, and site were negatively associated with follow-up colonoscopy, while Hispanic ethnicity and Asian race were positively associated with follow-up colonoscopy. Of 1702 BIRADS 4/5 mammograms, 1082 (64%) received a timely biopsy; only site was associated with timely follow-up biopsy.ConclusionDespite the vulnerabilities of public-hospital-system patients, follow-up of abnormal cancer screening tests occurs at rates similar to that of patients in other healthcare settings, with colon cancer screening test follow-up occurring at lower rates than follow-up of breast cancer screening tests. Site-level factors have larger, more consistent impact on follow-up rates than patient sociodemographic traits. Resources are needed to identify health system–level factors, such as test follow-up processes or data infrastructure, that improve abnormal cancer screening test follow-up so that effective health system–level interventions can be evaluated and disseminated.

Barriers associated with inadequate follow-up of abnormal fecal immunochemical test results in a safety-net system: A mixed-methods analysis

In safety-net healthcare systems, colonoscopy completion within 1-year of an abnormal fecal immunochemical test (FIT) result rarely exceeds 50%. Understanding how electronic health records (EHR) documented reasons for missed colonoscopy match or differ from patient-reported reasons, is critical to optimize effective interventions to address this challenge. We conducted a convergent mixed-methods study which included a retrospective analysis of EHR data and semi-structured interviews of adults 50–75 years old, with abnormal FIT results between 2014 and 2020 in a large safety-net healthcare system. Of the 299 patients identified, 59.2% (n = 177) did not complete a colonoscopy within one year of their abnormal result. EHR abstraction revealed a documented reason for lack of follow-up colonoscopy in 49.2% (n = 87/177); patient-level (e.g., declined colonoscopy; 51.5%) and multi-factorial reasons (e.g., lost to follow-up; 37.9%) were most common. In 18 patient interviews, patient (e.g., fear of colonoscopy), provider (e.g., lack of result awareness), and system-level reasons (e.g., scheduling challenges) were most common. Only three reasons for lack of colonoscopy overlapped between EHR data and patient interviews (competing health issues, lack of transportation, and abnormal FIT result attributed to another cause). In a cohort of safety-net patients with abnormal FIT results, the most common reasons for lack of follow-up were patient-related. Our analysis revealed a discordance between EHR documented and patient-reported reasons for lack of colonoscopy after an abnormal FIT result. Mixed-methods analyses, as in the present study, may give us the greatest insight into modifiable determinants to develop effective interventions beyond quantitative and qualitative data analysis alone.

Colonoscopy Following an Abnormal Fecal Test Result from an Annual Colorectal Cancer Screening Program in a Federally Qualified Health Center.

Individuals with an abnormal fecal immunochemical test (FIT) result have an elevated risk of colorectal cancer, and the risk increases if the follow-up colonoscopy is delayed. Of note, rates of follow-up colonoscopy are alarmingly low in federally qualified health centers (FQHCs), US health care settings that serve a majority racial and ethnic minority patient population. We assessed factors associated with colonoscopy after an abnormal FIT result and used chart-abstracted data to assess reasons (including process measures) for lack of follow-up as part of an annual, mailed-FIT outreach program within a large, Latino-serving FQHC. As part of the National Institutes of Health-funded PROMPT study, we identified patients with an abnormal FIT result and used logistic regression to assess associations between patient demographics and receipt of follow-up colonoscopy, controlling for patients' preferred language. We report on time (days) to referral and time to colonoscopy. For charts with an abnormal FIT result but no evidence of colonoscopy, we performed a manual abstraction and obtained the reason for the absence of colonoscopy. When there was no evidence of colonoscopy in a patient's electronic health record (EHR), we performed an automated query of the administrative claims database to identify colonoscopy outcomes. We identified 324 patients with abnormal FIT results from July to October 2018. These patients were mostly publicly insured (Medicaid 53.1%, Medicare 14.5%), 81.8% were aged 50 to 64 years, 55.3% were female, 80.3% were Hispanic/Latino, and 67.3% preferred to speak Spanish. We found that 108/324 (33.3%) patients completed colonoscopy within 12 months, and the median time to colonoscopy was 94 days (IQR: 68-176). Common barriers to colonoscopy completion, obtained from chart-abstracted data, were: no documentation following referral to gastrointestinal (GI) specialist or GI consultation (41.6%), no referral to GI specialist following abnormal fecal test (34.2%), and absence of a valid insurance authorization (6.5%). Multi-level strategies are needed to provide optimal care across the cancer continuum for FQHC patients. In order to reduce the risk of CRC and realize the return on fecal testing investment, concerted system-level efforts are urgently needed to improve rates of follow-up colonoscopy among FQHC patients and redress racial and ethnic disparities in CRC screening outcomes.

Abstract PO-042: Incorporating Latino patient input in messaging for follow-up colonoscopy after abnormal fecal testing

Abstract Introductory sentences indicating the purposes of the study: We used boot camp translation (BCT), a validated community based participatory strategy, to elicit input from diverse stakeholders (i.e., patients and clinic staff) to develop messaging and patient education materials for follow-up colonoscopy after abnormal fecal testing. BCT is a process that engages participants in translating health information into ideas, messages, and materials that are understandable and relevant to patients. Brief description of pertinent experimental procedures: Colorectal cancer is the second-leading cause of cancer death in the United States, and screening rates are disproportionately low among Latinos. Mailed fecal immunochemical test (FIT) outreach programs have been shown to improve colorectal cancer screening rates in federally qualified health centers (FQHCs), with improvements ranging from 22% – 45%. Patients with an abnormal FIT result have an increased risk of having colorectal cancer, and the risk increases if the necessary follow-up colonoscopy is delayed. Unfortunately, rates of follow-up colonoscopy among adults with an abnormal FIT result are low in FQHCs. As part of the Participatory Research to Advance Colon Cancer Prevention (PROMPT) study, a partnership with a Los Angeles-based FQHC that provides medical services to over 300,000 patients annually (82% Latino), we used BCT to gather input from patients and staff to develop messaging and materials for patients in need of a follow-up colonoscopy after abnormal FIT. Due to the COVID-19 pandemic, we conducted BCT using a digital platform. Eligible patient participants were Latino, ages 50 to 75 years, Spanish-speaking, and willing to participate in three virtual sessions. Recruitment and BCT materials were developed in English and Spanish, but all three sessions were held in Spanish consistent with patient preferences. The sessions included presentations on colorectal cancer screening, effective messaging to improve Latino screening participation, and brainstorming sessions to obtain feedback on messaging and materials. Summary of the new unpublished data: A total of 10 adults (7 patients and 3 clinic staff) participated in the BCT sessions. Key themes learned were 1) increasing awareness about the colonoscopy procedure (why it is important, what the procedure is, how to prepare), 2) using simple and clear wording, including statistics, and using family as a motivator, and 3) providing different patient outreach modalities to broaden reach, such as patient-facing fact sheets, videos in clinic or sent by text. Statement of the conclusions: Using BCT, we successfully incorporated feedback from Spanish-speaking Latino patients to design culturally relevant materials to promote follow-up colonoscopy after abnormal FIT results. Targeted efforts are needed to improve rates of follow-up colonoscopy among patients with abnormal FIT results in FQHC settings. (Final materials, including patient-facing fact sheets and screenshots from short videos, will be showcased in the poster.) Citation Format: Jamie H. Thompson, Jennifer Rivelli, Anne Escaron, Joanna Garcia, Esmeralda Ruiz, Evelyn Torres-Ozadali, Dawn Richardson, Priyanka Gautom, Gloria Coronado. Incorporating Latino patient input in messaging for follow-up colonoscopy after abnormal fecal testing [abstract]. In: Proceedings of the AACR Virtual Conference: 14th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2021 Oct 6-8. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2022;31(1 Suppl):Abstract nr PO-042.

The impact of cumulative colorectal cancer screening delays: A simulation study.

Annual fecal immunochemical tests can reduce colorectal cancer incidence and mortality. However, screening is a multi-step process and most patients do not perfectly adhere to guideline-recommended screening schedules. Our objective was to compare the reduction in colorectal cancer incidence and life-years gained based on US guideline-concordant fecal immunochemical test screening to scenarios with a range of delays. The Colorectal Cancer Simulated Population model for Incidence and Natural history (CRC-SPIN) microsimulation model was used to estimate the effect of systematic departures from fecal immunochemical test screening guidelines on lifetime screening benefit. The combined effect of consistent modest delays in screening initiation (1 year), repeated fecal immunochemical test screening (3 months), and receipt of follow-up or surveillance colonoscopy (3 months) resulted in up to 1.3 additional colorectal cancer cases per 10,000, 0.4 additional late-stage colorectal cancer cases per 10,000 and 154.7 fewer life-years gained per 10,000. A 5-year delay in screening initiation had a larger impact on screening effectiveness than consistent small delays in repeated fecal immunochemical test screening or receipt of follow-up colonoscopy after an abnormal fecal immunochemical test. The combined effect of consistent large delays in screening initiation (5 years), repeated fecal immunochemical test screening (6 months), and receipt of follow-up or surveillance colonoscopy (6 months) resulted in up to 3.7 additional colorectal cancer cases per 10,000, 1.5 additional late-stage colorectal cancer cases per 10,000 and 612.3 fewer life-years gained per 10,000. Systematic delays across the screening process can result in meaningful reductions in colorectal cancer screening effectiveness, especially for longer delays. Screening delays could drive differences in colorectal cancer incidence across patient groups with differential access to screening.

Centralized colorectal cancer screening outreach and patient navigation for vulnerable populations in North Carolina: study protocol for the SCORE randomized controlled trial

BackgroundAlthough colorectal cancer (CRC) screening is effective in reducing CRC mortality, screening rates in vulnerable populations served by community health centers (CHCs) remain below national targets. CHCs in North Carolina are challenged to reach CRC screening targets as they tend to be under-resourced, have limited capacity to implement and sustain population health interventions, and typically operate independently from one another and from regional colonoscopy providers. The Scaling Colorectal Cancer Screening Through Outreach, Referral, and Engagement (SCORE) project is designed to address barriers to CRC screening in partnership with CHCs by implementing a multilevel intervention that includes centralized support infrastructure for mailed fecal immunochemical test (FIT) outreach and patient navigation to follow-up colonoscopy. This paper describes protocols for the SCORE implementation trial.MethodsWe will conduct a type 2 hybrid effectiveness-implementation trial that will assess effectiveness at increasing CRC screening and follow-up rates while also assessing implementation outcomes. The planned trial sample will include 4000 CHC patients who are at average CRC risk and due for screening. Participants will be randomized 1:1 to receive either usual care or a multilevel intervention that includes mailed FIT outreach and patient navigation support to follow-up colonoscopy for those with abnormal FIT. The primary effectiveness outcome is completion of any CRC screening test at six months after randomization. We will also conduct a multilevel assessment of implementation outcomes and determinants.DiscussionThis hybrid effectiveness-implementation trial will evaluate the effectiveness and implementation of an intervention that provides centralized infrastructure for mailed FIT screening and patient navigation for CHCs that operate independently of other healthcare facilities. Findings from this research will enhance understanding of the effectiveness of a centralized approach and factors that determine successful implementation in vulnerable patient populations.Trial registrationThe trial was registered on May 28, 2020, at ClinicalTrials.gov (identifier NCT04406714).