Positive Colorectal Cancer Screening Test Research Articles

Diffuse colonic capillary hemangioma mimicking ulcerative colitis.

Inflammatory bowel disease (IBD) diagnosis requires clinical, laboratory, endoscopic and histologic findings, and sometimes it can become a challenge. An exhaustive differential diagnosis with infectious disease, immunodeficiencies, hematologic, neoplastic, or vascular diseases must be made1, since prognosis and treatment vary depending on etiology. We present the case of a 62-year-old man, with no personal history of interest, who undergoes a colonoscopy after a positive colorectal cancer screening test (fecal occult blood test). In the endoscopy, a continuous involvement was observed from the anal margin to the splenic flexure, with erythematous mucosa, loss of vascular pattern, and alternating scar areas with neovessels. Histopathological findings were compatible with diffuse capillary hemangioma. Since no symptoms of gastrointestinal (GI) bleeding nor anemia were referred, periodic surveillance was carried out.

Impact of Eliminating Cost-Sharing by Medicare Beneficiaries for Follow-Up Colonoscopy After a Positive Stool-based Colorectal Cancer Screening Test.

A follow-up colonoscopy after a positive stool-based colorectal cancer screening test is necessary to complete the full screening process. Policies that remove cost barriers to completing colorectal cancer screening may lead to increases in overall participation rates and use of follow-up colonoscopy, improving clinical and economic outcomes.

Estimated life-years gained and resultant cost savings from follow-up colonoscopy after a positive multi-target stool DNA (mt-sDNA) test for colorectal cancer screening in commercially insured and Medicare populations.

6642 Background: Although follow up colonoscopy (COL) after a positive stool-based colorectal cancer (CRC) screening test is necessary to complete the CRC screening process, follow-up COL rates remain suboptimal, especially among underserved populations. As of January 2023, federal policies require commercial insurers and Medicare to eliminate out of pocket costs for follow-up COL. To estimate the implications of this policy change, we compared the clinical and fiscal outcomes for a simulated cohort receiving a follow-up COL after a non-invasive CRC test ($0 cost sharing), compared to the same cohort not completing follow-up COL (status quo). Methods: Using the validated CRC-AIM model, we simulated a cohort of 6 million average-risk individuals who received mt-sDNA (commercial patients at age 45 and Medicare patients at age 65) and further analyzed only the population with positive mt-sDNA. Life-years gained, CRC incidence, CRC-related mortality and total costs of care (inclusive of CRC screening and treatment) were calculated for a cohort that underwent follow-up COL and compared these outcomes to that same cohort that did not complete follow-up COL. The cost of follow-up COL was assumed to be $1,576 for Medicare and $3,086 for commercially insured patients ($0 out of pocket costs for all). Results: Patients undergoing follow-up COL after a positive mt-sDNA experienced more life-years (83 per 1,000 commercially insured patients and 80 per 1,000 Medicare beneficiaries) compared to those who did not undergo follow-up COL. The follow-up COL resulted in reductions in CRC incidence and CRC mortality by 14% and 16% for commercial and 19% and 23% for Medicare beneficiaries, respectively. Compared to those patients with a mt-sDNA positive test result and did not complete follow-up COL, the total cost per patient for those receiving follow-up COL was $3,339 less for commercially insured ($15,690 – no follow up vs. $12,351 – follow up) and $4,382 less for Medicare beneficiaries ($19,337 – no follow up vs. $14,955 – follow up). Total spending for patients receiving follow-up COL was cost-saving when compared to no follow-up as long as the COL costs were less than $6,269 for commercial plans and $5,753 for Medicare. Conclusions: Completing a follow-up COL after a positive mt-sDNA screening saves lives, enhances equity, and lowers total expenditures. Thus, health care stakeholders should invest in efforts to identify and reduce barriers that ultimately lead to an increase uptake of this potentially lifesaving and cost-reducing intervention.

Cost-Effectiveness of Waiving Coinsurance for Follow-Up Colonoscopy after a Positive Stool-Based Colorectal Screening Test in a Medicare Population.

Follow-up colonoscopy after a positive stool-based test is necessary to complete the colorectal cancer-screening process. This analysis demonstrated that in a simulated Medicare population, waiving coinsurance for a follow-up colonoscopy improved estimated outcomes and was cost-effective when it was assumed that waiving the coinsurance modestly increased screening adherence. See related Spotlight, p. 641.

Cost-effectiveness of waiving coinsurance for follow-up colonoscopy after a positive stool-based colorectal screening test in a Medicare population.

e13624 Background: Commercial insurance plans are required to cover, with no patient cost sharing, a follow-up colonoscopy (COL) after a positive stool-based colorectal cancer (CRC) screening test. Medicare beneficiaries may still be responsible for 20% coinsurance for a follow-up COL, posing a financial barrier to screening completion. Removing the coinsurance may increase screening adherence and improve outcomes. The estimated cost-effectiveness of stool-based CRC screening was compared among adherence scenarios that assumed the status quo (20% coinsurance for follow-up COL) or waived follow-up COL coinsurance. Methods: The CRC-AIM microsimulation model simulated US Medicare beneficiaries undergoing stool-based CRC screening between ages 65-75 years. Outcomes of total costs, total quality adjusted life years (QALYs), life-years gained (LYG), CRC incidence reductions (IR), and CRC mortality reductions (MR) were calculated per 1000 individuals versus no screening using the weighted average of the outcome with multitarget stool DNA, fecal immunochemical test, and fecal occult blood test, scaled by their estimated use. Costs of follow-up COL were assumed to have 20% coinsurance in the status quo scenario. Four comparative scenarios assumed that waiving coinsurance increased published, real-world stool-based screening or follow-up COL adherence rates by 5% or 10%. Results: In scenarios where waiving coinsurance was assumed to increase screening and/or follow-up COL adherence, up to 21 more LYG and greater IR and MR were observed vs the status quo (Table). Total costs in waived coinsurance scenarios (≥$6,398) were comparable to the status quo ($6,449) as the cost savings in CRC care offset the increased COL costs. Total QALYs in waived coinsurance scenarios (≥9.3671) were greater than the status quo (9.3643) because of improved clinical outcomes. Stool-based testing in waived coinsurance scenarios was either dominant (more effective and less costly) or cost-effective at $50,000/QALY with minimal incremental costs vs the status quo. Conclusions: In a simulated Medicare population, clinical CRC outcomes improved and stool-based screening was cost-effective or cost-saving when waiving the 20% coinsurance was assumed to modestly (5%) increase adherence rates for total CRC screening and/or a COL following a positive test. [Table: see text]

Motives for non-adherence to colonoscopy advice after a positive colorectal cancer screening test result: a qualitative study

Setting Participants with a positive faecal immunochemical test (FIT) in screening programs for colorectal cancer (CRC) have a high risk for colorectal cancer and advanced adenomas. They are therefore recommended follow-up by colonoscopy. However, more than ten percent of positively screened persons do not adhere to this advice. Objective To investigate FIT-positive individuals’ motives for non-adherence to colonoscopy advice in the Dutch CRC screening program. Subjects Non-adherent FIT-positive participants of the Dutch CRC screening program. Design We conducted semi structured in-depth interviews with 17 persons who did not undergo colonoscopy within 6 months after a positive FIT. Interviews were undertaken face-to-face and data were analysed thematically with open coding and constant comparison. Results All participants had multifactorial motives for non-adherence. A preference for more personalised care was described with the following themes: aversion against the design of the screening program, expectations of personalised care, emotions associated with experiences of impersonal care and a desire for counselling where options other than colonoscopy could be discussed. Furthermore, intrinsic motives were: having a perception of low risk for CRC (described by all participants), aversion and fear of colonoscopy, distrust, reluctant attitude to the treatment of cancer and cancer fatalism. Extrinsic motives were: having other health issues or priorities, practical barriers, advice from a general practitioner (GP) and financial reasons. Conclusion Personalised screening counselling might have helped to improve the interviewees’ experiences with the screening program as well as their knowledge on CRC and CRC screening. Future studies should explore whether personalised screening counselling also has potential to increase adherence rates. Key points Participants with a positive FIT in two-step colorectal cancer (CRC) screening programs are at high risk for colorectal cancer and advanced adenomas. Non-adherence after an unfavourable screening result happens in all CRC programs worldwide with the consequence that many of the participants do not undergo colonoscopy for the definitive assessment of the presence of colorectal cancer. Little qualitative research has been done to study the reasons why individuals participate in the first step of the screening but not in the second step. We found a preference for more personalised care, which was not reported in previous literature on this subject. Furthermore, intrinsic factors, such as a low risk perception and distrust, and extrinsic factors, such as the presence of other health issues and GP advice, may also play a role in non-adherence. A person-centred approach in the form of a screening counselling session may be beneficial for this group of CRC screening participants.

S0279 Predicted Colorectal Cancer Outcomes With Reported Adherence to Follow-Up Colonoscopy After a Positive Stool-Based Test

INTRODUCTION: Colonoscopy (COL) non-adherence following a positive non-invasive colorectal cancer (CRC) screening test (e.g., multitarget stool DNA [mt-sDNA], fecal immunochemical test [FIT]) undermines the achievable benefits of screening. Given wide variations in the limited data reporting COL adherence after a positive non-invasive test, microsimulation modeling was used to estimate the clinical implications of this understudied input. METHODS: An average-risk US population cohort free of diagnosed CRC at age 40 that underwent triennial mt-sDNA or annual FIT screening from ages 50 to 75 was simulated using the validated CRC-AIM model. Three scenarios were modeled: (S1) assumed 100% adherence for initial screening and COL follow-up; (S2) reported adherence rates for initial mt-sDNA (71%) or FIT (43%) screening, with assumed 100% adherence to COL follow-up; and (S3) reported adherence rates for initial mt-sDNA or FIT screening and reported adherence rates for COL follow-up after positive mt-sDNA (73%) or FIT (47%). Sensitivity analyses were performed using 100% and reported adherence rates for mt-sDNA and FIT screening, with COL follow-up adherence ranging from 40%-100%. Patients without a COL follow-up were assumed to be non-adherent until CRC symptom onset. Outcomes for each scenario are per 1000 individuals. RESULTS: S1, S2, and S3 each yielded life-years gained (LYG) and reductions in CRC incidence and CRC mortality with either mt-sDNA or FIT screening vs no CRC screening (Table 1). Estimated LYG for mt-sDNA and FIT were 297 and 316 for S1, 284 and 245 for S2, and 203 and 113 for S3, respectively. Reductions in CRC incidence for mt-sDNA and FIT were 64% and 68% for S1, 61% and 50% for S2, and 43% and 23% for S3, respectively; reductions in CRC mortality were 72% and 76% for S1, 69% and 59% for S2, and 49% and 27% for S3, respectively. With assumed 100% adherence to mt-sDNA or FIT screening, the LYG transition was at 45% (LYG = 128) and 40% (LYG = 119) adherence for COL follow-up, respectively (Figure 1). At reported adherence for stool-tests, the additional LYG for mt-sDNA vs FIT ranged from 12 to 188 as follow-up COL adherence increased from 40% to 100% (Figure 2). CONCLUSION: These modeling analyses demonstrate that the inclusion of more realistic estimates for mt-sDNA, FIT, and COL follow-up adherence has substantial impact on the predicted outcomes. Using reported adherence rates, rather than assuming 100% adherence, mt-sDNA yields greater CRC screening benefits vs FIT.Table 1.: Predicted life-years gained (LYG), colorectal cancer (CRC) incidence reduction, and CRC mortality reduction for triennial multitarget stool DNA (mt-sDNA) and annual fecal immunochemical test (FIT) in 3 different adherence scenarios per 1000 individuals free of diagnosed colorectal cancer at age 40 and screened between 50–75 yearsFigure 1.: Percent difference in predicted life-years gained (LYG) per 1000 individuals assuming 100% adherence for triennial multitarget stool DNA (mt-sDNA) and annual fecal immunochemical test (FIT) at assumed adherence rate intervals for follow-up colonoscopy (COL) in individuals free of diagnosed colorectal cancer at age 40 and screened between 50–75 years. White boxes indicate 10% positive difference with mt-sDNA versus FIT. Dark gray boxes indicate >10% negative difference with mt-sDNA versus FIT.Figure 2.: Percent difference in predicted life-years gained (LYG) per 1000 individuals by reported adherence rates for triennial multitarget stool DNA (mt-sDNA) and annual fecal immunochemical test (FIT) at assumed adherence rate intervals for follow-up colonoscopy (COL) in individuals free of diagnosed colorectal cancer at age 40 and screened between 50–75 years. White boxes indicate 10% positive difference with mt-sDNA versus FIT. Dark gray boxes indicate >10% negative difference with mt-sDNA versus FIT.

Lack of Association between Red Meat Consumption and a Positive Fecal Immunochemical Colorectal Cancer Screening Test in Khon Kaen, Thailand: a Population- Based Randomized Controlled Trial

Background:There is convincing evidence from epidemiological studies that meat consumption increases colorectal cancer (CRC) risk. However, assessment of any association with a positive fecal immunochemical test (FIT) in CRC screening has been limited. If a link could be shown this might be helpful for establishing a risk group for colonoscopy.Objective:This study aimed to assess any association between meat consumption and other lifestyle factors and a positive FIT result in a Thai population.Methods:A cross-sectional analytical study was conducted with 1,167 participants in a population-based randomized controlled trial. CRC was screened from May 2016 - February 2017. Subjects aged 45-74 years who met the eligibility criteria were randomly allocated to the study arm. A positive FIT was determined with cut-off 100 ng/mL. Multiple logistic regression was used to analyze any relationship between lifestyle factors and a positive FIT.Result:The total number of subjects was 1,060 (90.8% return rate of FIT). With FIT100, FIT150, and FIT200, positive tests were found in 92 (8.68%), 74 (6.98%), and 60 (5.66%), respectively. No significant associations were noted with any of the variables, except for being aged 60-74 years (ORadj = 1.62, 95%CI: 1.03-2.54) Borderline significance was observed for high consumption of vegetables (ORadj = 0.62, 95%CI: 0.36-1.07) and being male (ORadj = 1.39, 95%CI:0.87-2.22).Conclusion:Despite the evidence from the literature, no association was here found between a positive FIT result and meat consumption or other well-established lifestyle parameters. Being aged 60-74 years was a risk factor which should be taken into account in CRC screening strategy in countries like Thailand with limited access to endoscopy.

Quality Indicators in Colonoscopy.

Colonoscopy is one of the most commonly performed endoscopic procedures. It is the gold standard examination for work-up of colonic symptoms, for follow-up of positive colorectal cancer screening tests and for detection and removal of neoplastic polyps. Colonoscopy is a complex and invasive procedure with a potential not only for colorectal cancer prevention, but also for serious complications. Numerous factors may affect the balance of benefit versus harm of colonoscopy, including the performance of the endoscopist. These factors are commonly called quality indicators. As an increasing number of countries are recommending the general population to undergo colorectal cancer screening, the quality of colonoscopy should be considered a public health concern. Key quality indicators have been identified, and several professional organizations have issued recommendation statements to promote high-quality colonoscopy. To achieve high quality, these key quality indicators must be monitored, results must be analysed, and measures must be undertaken to correct substandard performance. High-quality training in colonoscopy and polypectomy should be a quality assurance priority.

Incomplete diagnostic follow-up after a positive colorectal cancer screening test: a systematic review.

Colorectal cancer (CRC) screening using faecal occult blood or faecal immunological testing (FOBT/FIT) involves completion of a screening test-then if required a follow-up diagnostic test. A systematic review, of EMBASE, MEDLINE, the Cochrane Library and Google Scholar, of studies up to 2016. Studies explored characteristics behind, reasons for and interventions to reduce incomplete diagnostic testing after a positive FOBT/FIT in CRC screening. A total of 68 articles were included (63 studies). There is evidence of disparities in uptake by socioeconomic position and ethnicity, as well as geographic remoteness. Positive health beliefs, health knowledge and CRC screening attendance history are associated with increased diagnostic testing. Facets of organised screening, including performance feedback and funding improve follow-up-whilst guidelines increase diagnostic testing and reduce inappropriate exclusions. Between 2 and 11% of participants refuse follow-up, with perception of pain critical. Interventions, notably a screening specialist to aid the patient journey, as well as tracking and reminder systems, can increase diagnostic testing. Although rates of non-attendance in those eligible are low, this represents a group with health care need. Disparities must be eliminated to alleviate wider health inequity. Organised, screening can reduce incomplete diagnostic testing, as can accessible health information.

Time to Colonoscopy after Positive Fecal Blood Test in Four U.S. Health Care Systems

To reduce colorectal cancer mortality, positive fecal blood tests must be followed by colonoscopy. We identified 62,384 individuals ages 50 to 89 years with a positive fecal blood test between January 1, 2011 and December 31, 2012 in four health care systems within the Population-Based Research Optimizing Screening through Personalized Regimens (PROSPR) consortium. We estimated the probability of follow-up colonoscopy and 95% confidence intervals (CI) using the Kaplan-Meier method. Overall differences in cumulative incidence of follow-up across health care systems were assessed with the log-rank test. HRs and 95% CIs were estimated from multivariate Cox proportional hazards models. Most patients who received a colonoscopy did so within 6 months of their positive fecal blood test, although follow-up rates varied across health care systems (P <0.001). Median days to colonoscopy ranged from 41 (95% CI, 40-41) to 174 (95% CI, 123-343); percent followed-up by 12 months ranged from 58.1% (95% CI, 51.6%-63.7%) to 83.8% (95% CI, 83.4%-84.3%) and differences across health care systems were also observed at 1, 2, 3, and 6 months. Increasing age and comorbidity score were associated with lower follow-up rates. Individual characteristics and health care system were associated with colonoscopy after positive fecal blood tests. Patterns were consistent across health care systems, but proportions of patients receiving follow-up varied. These findings suggest that there is room to improve follow-up of positive colorectal cancer screening tests. Understanding the timing of colonoscopy after positive fecal blood tests and characteristics associated with lack of follow-up may inform future efforts to improve follow-up.

Quality indicators for colonoscopy.

Colonoscopy is widely used for the diagnosis and treatment of colonic disorders. Properly performed, colonoscopy is generally safe, accurate, and well tolerated by most patients. Visualization of the mucosa of the entire large intestine and distal terminal ileum is usually possible at colonoscopy. In patients with chronic diarrhea, biopsy specimens can help diagnose the underlying condition. Polyps can be identified and removed during colonoscopy, thereby reducing the risk of colon cancer. Colonoscopy is the preferred method to evaluate the colon in most adult patients with bowel symptoms, iron deficiency anemia, abnormal radiographic studies of the colon, positive colorectal cancer screening tests, postpolypectomy and postcancer resection surveillance, surveillance in inflammatory bowel disease, and in those with suspected masses. The use of colonoscopy has become accepted as the most effective method of screening the colon for neoplasia in patients over the age of 50 years and in younger patients at increased risk (1). The effectiveness of colonoscopy in reducing colon cancer incidence depends on adequate visualization of the entire colon, diligence in examining the mucosa, and patient acceptance of the procedure. Preparation quality affects the ability to perform a complete examination, the duration the procedure, and the need to cancel or reschedule procedures (2, 3). Ineffective preparation is a major contributor to costs (4). Longer withdrawal times have been demonstrated to improve polyp detection rates, (5‐7) and conversely, rapid withdrawal may miss lesions and reduce the effectiveness of colon cancer prevention by colonoscopy. The miss rates of colonoscopy for large (≥1 cm) adenomas may be higher than previously thought (8, 9) Thus, careful examinations are necessary to optimize the effectiveness of recommended intervals between screening and surveillance examinations. Finally, technical expertise will help prevent complications that can offset any cost benefit ratio gained by removing neoplastic lesions. The following quality indicators have been selected to establish competence in performing colonoscopy and help define areas for continuous quality improvement. The levels of evidence supporting these quality indicators were graded according to Table 1. PREPROCEDURE The preprocedure period encompasses the time from first contact by the patient until administration of sedation or instrument insertion. The aspects of patient care addressed in prior documents apply here as well, including timely scheduling, patient preparation, identification, history and physical examination, appropriate choice of sedation and analgesia, evaluation of bleeding risk, etc. Because many examinations are currently being performed for colon cancer screening and are elective, care must be taken to be certain that all potential risks have been reduced to as low as practically achievable. The American Society for Gastrointestinal Endoscopy (ASGE) (10) and the U.S. Multi-Society Task Force on Colon Cancer have published appropriate indications for colonoscopy (11) (Tables 2 and 3).

Results of nurse navigator follow-up after positive colorectal cancer screening test: a randomized trial.

Follow-up after a positive colorectal cancer screening test is necessary for screening to be effective. We hypothesized that nurse navigation would increase the completion of colonoscopy after a positive screening test. This study was conducted between 2008 and 2012 at 21 primary care medical centers in western Washington State. Participants in the Systems of Support to Increase Colorectal Cancer Screening study who had a positive fecal occult blood test (FOBT) or flexible sigmoidoscopy needing follow-up were randomized to usual care (UC) or a nurse navigator (navigation). UC included an electronic health record-based positive FOBT registry and physician reminder system. Navigation included UC plus care coordination and patient self-management support from a registered nurse who tracked and assisted patients until they completed or refused colonoscopy. The primary outcome was completion of colonoscopy within 6 months. After 6 months, both groups received navigation. We randomized 147 participants with a positive FOBT or sigmoidoscopy. Completion of colonoscopy was higher in the intervention group at 6 months, but differences were not statistically significant (91.0% in navigation group vs 80.8% in UC group; adjusted difference, 10.1%; P = .10). Reasons for no or late colonoscopies included refusal, failure to schedule or missed appointments, concerns about risks or costs, and competing health concerns. Navigation did not lead to a statistically significant incremental benefit at 6 months. Follow-up rates after a positive colorectal cancer (CRC) screening test are high in a health care system where UC included a registry and physician reminders. Because of high follow-up rates in a health care system where UC included a registry and physician reminders, and small sample size, we cannot rule out incremental benefits of nurse navigation.

Optimizing adequacy of bowel cleansing for colonoscopy: recommendations from the US Multi-Society Task Force on Colorectal Cancer.

Optimizing Adequacy of Bowel Cleansing for Colonoscopy: Recommendations From the US Multi-Society Task Force on Colorectal Cancer

Optimizing adequacy of bowel cleansing for colonoscopy: recommendations from the U.S. Multi-Society Task Force on Colorectal Cancer

Colorectal cancer (CRC) is the second leading cause of cancer-related deaths in the United States.(1) Colonoscopy can prevent CRC by the detection and removal of precancerous lesions. In addition to CRC screening and surveillance, colonoscopy is used widely for the diagnostic evaluation of symptoms and other positive CRC screening tests. Regardless of indication, the success of colonoscopy is linked closely to the adequacy of preprocedure bowel cleansing. Unfortunately, up to 20%-25% of all colonoscopies are reported to have an inadequate bowel preparation.(2,3) The reasons for this range from patient-related variables such as compliance with preparation instructions and a variety of medical conditions that make bowel cleansing more difficult to unit-specific factors (eg, extended wait times after scheduling of colonoscopy).(4) Adverse consequences of ineffective bowel preparation include lower adenoma detection rates, longer procedural time, lower cecal intubation rates, increased electrocautery risk, and shorter intervals between examinations.(3,5-7) Bowel preparation formulations intended for precolonoscopy cleansing are assessed based on their efficacy, safety, and tolerability. Lack of specific organ toxicity is considered to be a prerequisite for bowel preparations. Between cleansing efficacy and tolerability, however, the consequences of inadequate cleansing suggest that efficacy should be a higher priority than tolerability. Consequently, the choice of a bowel cleansing regimen should be based on cleansing efficacy first and patient tolerability second. However, efficacy and tolerability are closely interrelated. For example, a cleansing agent that is poorly tolerated and thus not fully ingested may not achieve an adequate cleansing. The goals of this consensus document are to provide expert, evidence-based recommendations for clinicians to optimize colonoscopy preparation quality and patient safety. Recommendations are provided using the Grades of Recommendation Assessment, Development and Evaluation (GRADE) scoring system, which weighs the strength of the recommendation and the quality of the evidence.(8)

Mo1176 Screening the Worried Well: Symptomatic Individuals Are Less Likely to Have Significant Neoplasia At Colonoscopy Following a Positive Colorectal Cancer Screening Test

Mo1176 Screening the Worried Well: Symptomatic Individuals Are Less Likely to Have Significant Neoplasia At Colonoscopy Following a Positive Colorectal Cancer Screening Test

Evaluation of a VHA Collaborative to Improve Follow-up After a Positive Colorectal Cancer Screening Test

In 2005, the Veterans Health Administration initiated a yearlong Colorectal Cancer Care Collaborative (C4) to improve timely follow-up after positive fecal occult blood tests. Twenty-one facilities formed local quality improvement (QI) teams. Teams received QI training, created process flow maps, implemented process changes, and shared learning through 2 face-to-face meetings, conference calls, and a discussion board. We evaluated pre-post change in the timeliness of follow-up among C4 facilities and 3 control facilities. Outcome measures included the proportion of patients receiving a follow-up colonoscopy within 1 year, the proportion receiving 60-day follow-up (the focus of C4 teams), and average days to colonoscopy. Survey data from C4 team members was analyzed to identify predictors of facility-level improvement. Both C4 and control facilities improved on 1-year follow-up (10% and 9% increases, respectively, both P's<0.001). There was a statistically significant increase in the proportion receiving 60-day follow-up among C4 facilities (27% pre-C4 vs. 39% post-C4, P=0.008) but a nonsignificant decrease among control facilities (45% pre-C4 vs. 29% post-C4, P=0.14). Average days to colonoscopy decreased significantly among C4 facilities (129 pre-C4 vs. 103 post-C4, P=0.004) but increased significantly among control facilities (81 pre-C4 vs. 103 post-C4, P=0.04). Teams with the most improvement established clear roles/goals, had previous QI training, made more use of QI tools, and incorporated primary care education into their improvement work. A Veterans Health Administration improvement collaborative modestly decreased time to colonoscopy after a positive colorectal cancer screening test but significant room for improvement remains and benefits of participation were not realized by all facilities.

S1151 Experiences of General Practitioners Regarding Their Role in the Referral Process for Colonoscopy After a Positive Colorectal Cancer Screening Test

S1151 Experiences of General Practitioners Regarding Their Role in the Referral Process for Colonoscopy After a Positive Colorectal Cancer Screening Test

Timely Follow-Up of Positive Fecal Occult Blood Tests: Strategies Associated with Improvement

In light of previous research indicating that many patients fail to receive timely diagnostic follow-up of positive colorectal cancer (CRC) screening tests, the Veterans Health Administration (VA) initiated a national CRC diagnosis quality-improvement (QI) effort. This article documents the percent of patients receiving follow-up within 60 days of a positive CRC screening fecal occult blood test (FOBT) and identifies improvement strategies that predict timely follow-up. In 2007, VA facilities completed a survey in which they indicated the degree to which they had implemented a series of improvement strategies and described barriers to improvement. Three types of strategies were assessed: developing QI infrastructure, improving care delivery processes, and building gastroenterology capacity. Survey data were merged with a measure of 60-day positive-FOBT follow-up. Facility-level predictors of timely follow-up were identified and relationships among categories of improvement strategies were assessed. Data were analyzed in 2008. The median facility-reported 60-day follow-up rate for positive screening FOBTs was 24.5%. Several strategies were associated with timeliness of follow-up. The relationship between the implementation of QI infrastructure strategies and timely follow-up was mediated by the implementation of process-change strategies. Although constraints on gastroenterology capacity were often sited as a key barrier, implementation of strategies to address this issue was unassociated with timely follow-up. Developing QI infrastructure appears to be an effective strategy for improving FOBT follow-up when this work is followed by process improvements. Increasing gastroenterology capacity may be more difficult than improving processes of care.

Barriers to Full Colon Evaluation for a Positive Fecal Occult Blood Test

Failure to appropriately evaluate a positive cancer screening test may negate the value of doing that test. The primary aim of this study was to explore the factors associated with undergoing a full colon evaluation for a positive fecal occult blood test (FOBT) in a single Veterans Affairs center. Medical records of consecutive patients ages > or = 50 years, who had a positive screening FOBT from March 2000 to February 2001, were abstracted. Patient demographics, dates of ordering and doing follow-up test(s), and adherence with scheduled procedures were collected. The primary outcome, full colon evaluation, was defined as having a colonoscopy or double-contrast barium enema plus flexible sigmoidoscopy completed within 12 months. The sample (N = 538) was 98% men (58% Caucasian, 29% African-American, and 13% unknown race). Approximately 77% of the patients were referred to gastroenterology. Ultimately, only 44% underwent full colon evaluation within 12 months. Approximately 20% of the patients failed to attend a scheduled procedure. Referral to gastroenterology and adherence to follow-up appointments were associated with full colon evaluation. There was no association between African-American versus Caucasian race and full colon evaluation. Less than half of the patients with a positive FOBT had a full colon evaluation within 12 months. Multiple failures were identified, including lack of referral for further testing and patient nonadherence. Although the overall performance in evaluating a positive colorectal cancer screening test was poor, no racial disparity was observed.