Screening Colonoscopy Rates Research Articles

Changes in screening colonoscopy following Medicare reimbursement and cost-sharing changes.

To compare existing algorithms for classifying screening vs diagnostic colonoscopies and to quantify the increase in screening colonoscopy rates when Medicare began reimbursement in 2001 and when the Affordable Care Act (ACA) eliminated cost-sharing. Twenty percent random sample of fee-for-service (FFS) Medicare claims, 2000-2012. Using recent administrative codes as tarnished gold standards, we examined the sensitivity and specificity of five published algorithms for classifying colonoscopies and calculated annual screening colonoscopy rates. We estimated the change in rates after Medicare began reimbursement and used difference-in-differences analysis to estimate the effects of eliminating cost-sharing by comparing states with and without a mandate to cover screening colonoscopy prior to the ACA. Model-based algorithms have higher sensitivity (0.53-0.99) than expert-based algorithms (0.35-0.39), but lower specificity (0.43-0.65 vs 0.79-0.88). All algorithms detected increases in screening from both Medicare's reimbursement change (range: 24-93/10000) and the 2011 cost-sharing change (range: 1.1-34/10000). Difference-in-difference estimates of the ACA's effect varied from 51 to 155 tests per 10000 depending on the algorithm. Screening colonoscopy rates increased after eliminating cost-sharing in 2011, but the increase's size varied depending on the algorithm used to classify the indication. Improvements are needed in Medicare coding for screening.

Development of a tablet app designed to improve African Americans' screening colonoscopy rates.

Compared with other racial/ethnic groups, African Americans have the highest colorectal cancer (CRC) morbidity and mortality rates. It is critical to help improve African Americans' CRC prevention efforts in order to reduce the burden of CRC in this community. The aim of this study was to develop and field test a tablet app, called e-Motivate, designed to improve African Americans' screening colonoscopy rates. The e-Motivate app was field tested, using an iterative approach. The first version of the app, e-Motivate 1.0, was field tested on 20 African Americans over the age of 50. Participants engaged in a think aloud exercise and provided feedback regarding the app's usability and acceptability. The results of the first field test were used to modify the app and develop e-Motivate 2.0. The field test procedures were repeated on a new group of participants (N = 18). The results from the second field test were used to make final modifications to the app. Overall, participants responded positively to the app. Qualitative analyses showed that participants found the app to be easy to use and helpful. Furthermore, descriptive statistics revealed that participants found the app to be highly usable and acceptable, exceeding recommended benchmarks for usability and acceptability. Critiques of the app were used to modify and finalize the intervention. The results from the proposed study suggest that the e-Motivate app is highly feasible and acceptable. The next step in this line of research is to conduct a randomized clinical trial to formally test the efficacy of the e-Motivate app for improving screening colonoscopy rates among African Americans.

Invitation letters increase participation in colorectal cancer screening - results from an observational study.

Background and Aim Participation rates in the German colorectal cancer screening program are low. Starting in 2013, a large health insurance plan in Bavaria, Germany, is sending an additional invitation letter to insured individuals when they turn 50 or 55 years and become eligible for participation in the program. The letter provides detailed information on colorectal cancer screening. We assessed the impact of the invitation letter on utilization rates. Methods Insurance claims data of a total of 48 343 individuals who had turned 50 or 55 years between 2012 to 2014 were reviewed for utilization rates of screening colonoscopy and fecal blood tests. Utilization rates 1 year prior (2012) and 2 years after introduction of the invitation letter (2013 and 2014) were compared. Furthermore, providers of colorectal cancer screening were determined. Results Within 6 months after turning 50 or 55 years, 8.8 - 10.2 % of all insured individuals participated in colorectal cancer screening, with the majority being females. After the introduction of the invitation letter, a moderate increase in participation rates could be observed (increase to 109 % [RR 101.7 - 117.3 %, p = 0.02] in 2014). The uptake rate of screening colonoscopy was significantly higher in recipients of the letter (increase to 138.4 % [RR 110.4 - 173.8 %, p = 0.0043] in 2013 and to 149 % [RR 119.5 - 186.3 %, p = 0.0003] in 2014). Furthermore, a significantly higher proportion of general practitioners and gastroenterologists provided colorectal cancer screening in individuals receiving the invitation letter. Conclusions Introduction of an invitation letter can improve participation rates for colorectal cancer screening.

Wide Under- and Over-Estimation by PCPs Regarding Bleeding and Perforation Rates of Screening Colonoscopy

Introduction: Only about 62% of patients 50 years or older get Screening for Colorectal Cancer (SCRC). We surveyed Primary Care Physicians (PCPs) who are medical school faculty to find if they know how useful or harmful colonoscopy is, the estimates of survival they give to patients if colorectal cancer is found without screening, and what they think of newer Stool Based Methods (SBMs) for SCRC. Methods: An online anonymous Google survey was sent by email to PCPs at Family Medicine (FM) and Internal Medicine residency programs at Baylor College of Medicine and to a FM residency program at Eastern Virginia Medical School. Results: Of the 42 responses received, 60% were from FM; the setting was academic in 68%; 63% had been PCPs for over 10 years; and 65% estimated that their rate of SCRC was at national average. Their most common estimates respectively for annual Fecal Occult Blood Testing (FOBT), annual Fecal Immunnochemical Test (FIT), Cologuard every 3 years and colonoscopy every 10 years were 50-75%, 75-90%, 75-90% and >90% for sensitivity for SCRC, <50%, 50-75%, 75-90%, and >90% for sensitivity for screening for advanced adenomas, and 50-75%, 50-75%, 75-90% and >90% for specificity for SCRC. Although 44% of PCPs correctly estimated that rates of perforation and bleeding in screening colonoscopy are 4 in 10,000 and 8 in 10,000, 21% PCPs estimated them to be 4 in 1000 and 8 in 1000 and 30% PCPs estimated them to be 20 in 10,000 and 40 in 10,000 respectively. Although 56% of PCPs correctly estimated 5-year survival to be 90%, 70% and 10% respectively for screen-detected (stages 1 and 2), regional (stage 3) and distant (stage 4) cancer, 37% PCPs estimated this to be 90%, 50% and 5%. 38% PCPs thought colonoscopy was the same or only slightly better than SBMs, only 52% agreed that SBM should only be done if patients decline colonoscopy, and 19% did not prefer colonoscopy for SCRC. Conclusion: The estimates of PCPs regarding sensitivity and specificity of SCRC methods were similar to data reported by the US Preventive Task Force in 2016 except that PCPs under-estimated specificity of FOBT and FIT for SCRC and over-estimated specificity of Cologuard for screening of advanced adenomas. 37% PCPs under-estimated survival in advanced cancer. Although colonoscopy is recommended as the preferred modality of screening, 19% of PCPs did not prefer it. The most significant finding was that 21% PCPs underestimated perforation and bleeding rates during screening colonoscopy by 5 times, and 31% overestimated the rates by 5 times.

E-motivate: Development of an App To Improve African Americans’ Screening Colonoscopy Rates

Background: Colorectal cancer (CRC) is the third leading cause of death due to cancer in the United States. Compared to other racial/ethnic groups, African Americans have the highest CRC morbidity and mortality rates. Despite the proven efficacy of CRC screening, more than one-third of African Americans have not received a colonoscopy screening within the recommended time frame (one colonoscopy per ten years). It is critical to improve this group’s colonoscopy screening uptake to reduce the burden of CRC among African Americans. Objective: The primary goal was to develop a tablet app, e-motivate, which incorporates motivational interviewing principles to increase African Americans’ colonoscopy screening uptake. Two-step field testing was conducted to examine the app’s efficacy. Methods: Participants (N=40) were African American primary care patients over the age of 50 (recommended age to begin screening for CRC). Immediately after receiving a colonoscopy screening referral, patients field-tested e-motivate in the primary care office, which took approximately 20 minutes. For Field Test 1, 20 participants used the app and engaged in a think-aloud exercise to assess the intervention’s feasibility. The feedback from Field Test 1 was used to modify the app. Field test procedures were repeated on an additional 20 participants to confirm feasibility. The feedback from the Field Test 2 was used to further modify the app. Results: In Field Test 1, descriptive statistics were run to determine the usability and acceptability of the app. The mean overall score on the System Usability Scale of 86.62 (possible range from 0 to 100) indicates high usability. The mean score on the Acceptability E-Scale of 4.8 (possible range from 1 to 5) indicates high acceptability of the app. Qualitative thematic analysis revealed that participants found the e-motivate 1.0 app to be user-friendly and helpful. Some participants reported difficulty with certain app functions (e.g., using a slider icon). The participants’ suggestions were used to guide the development of the e-motivate app 2.0. Field Test 2 is ongoing and results will be reported in the final poster presentation. Iterations to follow will be based on patient feedback. Conclusions: The two-step field test approach focused on user-centered design and directly informed the development of a user-friendly, patient-driven app with optimal user satisfaction and engagement to help improve screening colonoscopy uptake in African Americans. The next critical step in the app’s development is to test the efficacy of e-motivate in a randomized clinical trial. If the app is successful in the RCT there is a strong case for integrating e-motivate into standard clinical practices with the ultimate goal of reducing the preventable and unequal burden of CRC among African Americans. In the future, the digital prescribing platform RxUniverse, an efficient program which enables physicians to “prescribe” evidence-based mobile health applications to a large population of patients, can be used to bulk prescribe e-motivate. Trial Registration: Improving Colonoscopy Screening Uptake to Reduce the Burden of CRC Among African Americans

Active Choice and Financial Incentives to Increase Rates of Screening Colonoscopy–A Randomized Controlled Trial

Behavioral economic approaches could increase uptake for colorectal cancer screening. We performed a randomized controlled trial of 2245 employees to determine whether an email containing a phone number for scheduling (control), an email with the active choice to opt in or opt out (active choice), or the active choice email plus a $100 incentive (financial incentive) increased colonoscopy completion within 3 months. Higher proportions of participants in the financial incentive group underwent screening (3.7%) than in the control (1.6%) or active choice groups (1.5%) (P= .01 and P < .01). We found no difference in uptake of screening between the active choice and control groups (P= .88). The $100 conditional incentive modestly but significantly increased colonoscopy use. ClinicalTrials.gov no: NCT02660671.

Anesthesia Service Use and the Uptake of Screening Colonoscopies.

The Center for Medicare & Medicaid Services recently defined "screening colonoscopy" to include separately furnished anesthesia services. To examine the relationship between anesthesia service use and the uptake of screening colonoscopies. We correlated metropolitan statistical area (MSA) level anesthesia service use rates, derived from the 2008, 2010, and 2012 Medicare and MarketScan claims data, with the presence of individual level guideline concordant screening colonoscopy using the Behavioral Risk Factor Surveillance System data for the same years. Proportion of colonoscopies with anesthesia service was calculated at the MSA level. A guideline concordant screening colonoscopy was defined as a colonoscopy received within the past 10 years. The average MSA level anesthesia service use rate in colonoscopy significantly increased from 25.34% in 2008 to 44.25% in 2012; but only a moderate increase in the rate of guideline concordant colonoscopies was observed, from 57.36% in 2008 to 65.32% in 2012. After adjusting for patient characteristics, we found a nonsignificant negative association between anesthesia service use rate and colonoscopy screening rate, with an odds ratio of 0.90 for receiving a guideline concordant colonoscopy for each percentage point increase in anesthesia service use rate (P=0.27). The relationship between anesthesia service use and the overall colorectal cancer screening rate followed the same pattern and was also not statistically significant. No significant association between anesthesia service use and colonoscopy screening or colorectal cancer screening rates was found, suggesting that more evidence is needed to support the Center for Medicare & Medicaid Services rule change.

Getting the first degree relatives to screen for colorectal cancer is harder than it seems-patients' and their first degree relatives' perspectives.

First degree relatives (FDR) of colorectal cancer (CRC) patients are at increased risk of CRC compared to the general population. However, screening colonoscopy rates amongst the FDRs remain dismal. The aim of the study was to explore the various issues amongst the patients and their FDR precluding their adoption of screening colonoscopy. A qualitative study of CRC patients and their FDRs was performed. Semi-structured interviews were conducted with participants using open-ended questions until data saturation was achieved. These qualitative data were then thematically analysed. Fifty CRC patients and thirty-one FDRs were recruited between June 2015 and December 2015. For the patients, three main themes emerged, which include (i) poor understanding of the CRC screening guidelines for their FDRs, (ii) recommendations are lacking amongst medical professionals and (iii) numerous barriers are hindering patients from being advocates for screening colonoscopy for their FDRs. For the FDRs, three main themes emerged. These include (i) poor understanding of the exact CRC screening guidelines amongst the FDRs, (ii) the lack of health promotion efforts amongst medical professionals and (iii) barriers to the uptake of screening colonoscopy such as fear of colonoscopy, high cost of the procedure, its associated inconvenience and perceived invulnerability of the individual. Patients and FDRs are not aware of the increased risks of developing CRC amongst the family members. Guidelines regarding screening are also not clearly understood. The numerous barriers that are present amongst the CRC patients and their FDRs can be addressed.

Abstract B80: Use of geographic information systems to visualize the screening colonoscopy referral network of the University of Chicago Medical Center

Abstract Background: In Illinois for the year 2015, colorectal cancer (CRC) is projected to cause 2,090 deaths, making it the leading cause of non-tobacco related cancer mortality. African American Illinois residents have an approximately 7% greater incidence and a 30% higher mortality rate when compared to white residents. Guideline consistent routine screening is known to reduce death due to CRC. Screening colonoscopy is the most commonly performed CRC screening test. However, African Americans are known to have low rates of screening colonoscopy and diagnostic colonoscopy completion compared to whites. Chicago's South Side includes 34 of the city's 77 recognized community areas and is home to a combined population of more than 800,000 residents, of whom greater than 75% are African American. The contiguous communities that make up the South Side cover approximately 60% of Chicago's land area. There are 41 facilities throughout Chicago that perform outpatient screening colonoscopy, of with 13 (32%) are located on Chicago's South Side. The University of Chicago Medical Center (UCMC) is the largest healthcare provider on the South Side and represents 30% of the local capacity for screening colonoscopy services. Objectives: The objectives of this study were to use geographic information systems (GIS) and geospatial analysis to explore the distribution of patients who completed a screening colonoscopy at the UCMC during calendar year 2014 and to visualize the associated physician referral network. Methods: A retrospective chart review was performed for all individuals who completed a screening colonoscopy during calendar year 2014 at UCMC. Screening colonoscopies were identified through CPT codes: G0105 (Colorectal cancer screening; colonoscopy on individual at high risk) and G0121 (Colorectal cancer screening; colonoscopy on individual no meeting criteria for high risk). Mapping and spatial analysis were performed using ArcMap version 10.1. Descriptive statistics were performed using STATA 13.1. Results: During calendar year 2014, 1632 outpatient screening colonoscopies were completed on 1592 patients (mean age, 59 years; 36% male; 49% AA, 29% white). Of the 1,632 screening colonoscopy procedures, 1,017 (62%) were completed on patients with ZIP codes located within Chicago's South Side (mean age, 59 years; 33% male; 63%AA, 17% white). Of the 1,017 colonoscopies performed on South Side residents, 102 (10%) were completed as a result of a referral from an external non-UCMC affiliated physician and 915 (90%) were completed as a result of a referral from a UCMC affiliated physician. Conclusions: The majority of patients who completed a screening colonoscopy at UCMC during calendar year 2014 were residents of the South Side. However, only 10% of the screening colonoscopies completed on South Side residents were related to referrals obtained from non-UCMC affiliated physicians. These results may indicate the presence of a weak referral network between the largest local healthcare provider, UCMC, and local South Side physicians for screening colonoscopy. Citation Format: Keith B. Naylor, Olufemi Kassim, Karen E. Kim. Use of geographic information systems to visualize the screening colonoscopy referral network of the University of Chicago Medical Center. [abstract]. In: Proceedings of the Eighth AACR Conference on The Science of Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; Nov 13-16, 2015; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2016;25(3 Suppl):Abstract nr B80.

Feasibility study of minimal prepared hydroflush screening colonoscopy.

Although screening colonoscopy is effective for early detection of colorectal cancer (CRC), screening rates remain low. Multiple factors are thought to be responsible for the low rates of screening colonoscopy, but bowel preparation appears to be a key deterrent. Tolerability issues with bowel preparations may lead to poor patient compliance, inadequate colon cleansing, and reduced detection of colonic polyps. The aim of this article is to evaluate the feasibility, safety, and outcomes of minimally prepared intra-procedural hydroflush technique as an alternative to traditional bowel preparation in screening colonoscopy. We conducted a prospective feasibility study of intraprocedural hydroflush technique aided by water-jet pumps and a mechanical suction novel device following minimal bowel preparation for CRC screening. Nine procedures were performed in nine healthy individuals scheduled for routine screening colonoscopy. Preparation included mild diet restriction, laxative tablets two to three days prior to the procedure and two Fleet enemas one to two hours before the colonoscopy. The cleanliness of the colon was assessed by using the Boston bowel preparation scale. Insertion and withdrawal times were recorded. Complete colonoscopy to the cecum was performed in all patients (100%). Mean time to the cecum was 5.78 ± 2.68 minutes, and mean withdrawal time was 15.33 ± 3.94 minutes. Endoscopic visualization of the entire mucosa was achieved in all cases with no colonoscopy repeated because of inadequate preparation. Four polyps have been detected and removed in three patients. Mild mucosal erosions were seen in some areas where the suction was used extensively, similar to those that can be seen during conventional colonoscopy. Mild stiffness of the shaft of the scope was noted. This was an uncontrolled feasibility study of selected patients. Minimally prepared colonoscopy with the intra-procedural hydroflush technique for colorectal screening is feasible. The water exchange technology compensates for the mild stiffness of the scope. This technique might increase patients' compliance for CRC screening.

Identification and correction of decreasing cancer screening colonoscopy rate during the economic recession

Identification and correction of decreasing cancer screening colonoscopy rate during the economic recession

Colonoscopy screening among US adults aged 40 or older with a family history of colorectal cancer.

IntroductionColonoscopy screening reduces colorectal cancer (CRC) incidence and mortality. CRC screening is recommended at age 50 for average-risk people. Screening of first-degree relatives of CRC patients is recommended to begin at age 40 or 10 years before the age at diagnosis of the youngest relative diagnosed with CRC. CRC incidence has increased recently among younger Americans while it has declined among older Americans. The objective of this study was to determine whether first-degree relatives of CRC patients are being screened according to recommended guidelines.MethodsWe studied colonoscopy screening rates among the US population reporting a CRC family history using 2005 and 2010 National Health Interview Survey data.ResultsOf 26,064 study-eligible respondents, 2,470 reported a CRC family history; of those with a family history, 45.6% had a colonoscopy (25.2% in 2005 and 65.8% 2010). The colonoscopy rate among first-degree relatives aged 40 to 49 in 2010 (38.3%) was about half that of first-degree relatives aged 50 or older (69.7%). First-degree relatives were nearly twice as likely as nonfirst-degree relatives to have a colonoscopy (adjusted odds ratio [AOR], 1.7; 95% confidence interval, 1.5–1.9), but those aged 40 to 49 were less likely to have a colonoscopy than those in older age groups (AOR, 2.6 for age 50–64; AOR, 3.6 for age ≥65). Interactions with age, insurance, and race/ethnicity were not significant. Having health insurance tripled the likelihood of screening.ConclusionDespite a 5-fold increase in colonoscopy screening rates since 2005, rates among first-degree relatives younger than the conventional screening age have lagged. Screening promotion targeted to this group may halt the recent rising trend of CRC among younger Americans.

Sa1020 Association of Use of Anesthesia Services During Colonoscopies and Colorectal Cancer Screening Rates

Background: Current guidelines recommend that the gastroenterologist-nurse team deliver sedation to low-risk patients undergoing colonoscopy screening. Yet a 2012 study demonstrated that professional anesthesia service (PAS) use increased from 14% in 2003 to over 30% in 2009, and more than two-thirds of PAS was delivered to low-risk patients. Recently, the Centers for Medicare and Medicaid Services stated PAS use was becoming the standard of care and proposed waiving the copayments for Medicare patients undergoing screening. The cost and benefits of this policy change are unknown. Objective: To estimate the association between PAS use in screening colonoscopies and colorectal cancer screening rates (benefit), and the PAS cost associated with each additional colorectal cancer prevented by increasing PAS use. Data: We used 2008-2012 Medicare claims data to derive the rate of PAS use for fee-for-service beneficiaries during colonoscopy, and 2008-2012 Behavioral Risk Factor Surveillance System Survey (BRFSS) data to estimate colorectal cancer screening rates. Methods: Rates for PAS, colonoscopy and overall cancer screening rates (including fecal occult blood test) were constructed for the 150 metropolitan statistical areas (MSA) that had both BRFSS and LDS data during 2008-2012. Colonoscopies and PAS use were identified based on CPT-4 codes, which were linked based on service date and location. The PAS rate was defined as the proportion of colonoscopies with PAS. The colonoscopy screening and colorectal cancer screening rates were defined as proportion of eligible individuals in compliance with the CDC's guideline on screenings. Sampling weights were used to generate MSA level estimates. Combining our estimates with those from the published literature, we approximated the increase in PAS cost associated with the detection of one additional case colorectal cancer. Results: From 2008 to 2012, colonoscopy screening rates increased from 63% to 70%, overall colorectal cancer screening rates from 71% to 75%, and PAS use from 32% to 42%. PAS use was positively correlated with colonoscopy screening rates (rho=0.180, p 0.050). PAS cost associated with each additional colorectal cancer prevented was estimated to be $16.6 million (95% CI: $11.0 million, $33.2 million) in 2014 U.S. dollars. Conclusions: PAS use in colonoscopies was modestly associated with colonoscopy screening rates but not with overall colorectal cancer screening rates. Improving coverage of PAS during screening colonoscopies is unlikely to increase screening in a cost-effective fashion.

Narrative message targets within the decision-making process to undergo screening colonoscopy among Latinos: a qualitative study.

Colorectal cancer (CRC) is a preventable yet leading cause of cancer mortality among Latinos in the USA. Cultural targeting and narrative messaging are two strategies to increase the low screening colonoscopy rates among Latinos. This study identifies key messages for educational interventions aiming to increase screening colonoscopy used among Latinos and proposes a model to understand the relationship between factors involved in colonoscopy decision-making. Individual in-depth interviews were conducted with 12 Latino participants primarily of Puerto Rican descent on the topics of CRC knowledge, barriers and facilitators to colonoscopy use, and the use of narrative in colorectal health messaging. Knowledge about colorectal anatomy and the anesthesia component of colonoscopy procedure is low. Fear of procedure-related pain and fear of treatment-related burden following a cancer diagnosis are significant barriers to colonoscopy. Fear of disease-related suffering and death following a cancer diagnosis and fear of regret are strong facilitators and can be augmented by cancer narratives. Storytelling is commonly used in Latino culture and is an acceptable method to educate the Latino community about CRC screening via colonoscopy. Machismo is a unique barrier to colonoscopy for Latino men via homophobia and reluctance to seek healthcare. A preliminary model to understand factors in colonoscopy decision-making among Latinos is presented. Counseling practices and educational interventions that use culturally targeted narrative health messaging to mediate fears and increase colonoscopy knowledge may increase screening colonoscopy use among Latinos.

Screening Colonoscopy among Uninsured and Underinsured Urban Minorities.

Background/AimsUninsured individuals have lower rates of screening colonoscopy (SC), and little is known regarding the pathology results obtained when they undergo colonoscopies. Since 2004, we have participated in a program that offers SC to uninsured New Yorkers; herein, we report our findings.MethodsUninsured, average-risk patients who were at least 50 years of age underwent SC at our institution between April 2004 and June 2011. We analyzed polyp pathology, location, size, incidence of adenomas, and incidence of adenomas with advanced pathology (AAP) with respect to ethnicity, gender, and age.ResultsOut of 493 referrals, 222 patients completed the colonoscopies. Polyps were identified in 21.2% of all patients; 14% had adenomas, and 4.5% had AAP. The rates of adenomas among African-Americans, Hispanics, and Whites were 24.3%, 12.1%, and 11.6%, respectively, and the corresponding rates of AAP were 10.8%, 3.5%, and 2.3%. Differences in the polyp type, location, and AAP did not reach statistical significance with respect to ethnicity or gender. Patients aged 60 and older were found to have a higher rate of advanced adenomas compared with younger patients (8.6% vs 2.6%, p=0.047).ConclusionsFurther efforts to fund screening colonoscopies for uninsured individuals will likely result in the identification of advanced lesions of the colon before they progress to colorectal cancer.

Predicting Colonoscopy Completion Among African American and Latino/a Participants in a Patient Navigation Program.

Patient navigation (PN) effectively increases screening colonoscopy (SC) rates, a key to reducing deaths from colorectal cancer (CRC). Ethnic minority populations have disproportionately low SC rates and high CRC mortality rates and, therefore, especially stand to benefit from PN. Adapting the Health Belief Model as an explanatory model, the current analysis examined predictors of SC rates in two randomized studies that used PN to increase SC among 411 African American and 461 Latino/a patients at a large urban medical center. Speaking Spanish but not English (odds ratio (OR), 2.192; p < 0.005), having a higher income (OR, 1.218; p < 0.005), and scoring higher on the Pros of Colonoscopy scale (OR, 1.535; p = 0.023) independently predicted colonoscopy completion. Health education and PN programs that increase awareness of the benefits of getting a colonoscopy may encourage colonoscopy completion. In the context of language-appropriate PN programs for African American and Latino/a individuals, those with lower incomes and English speakers may require additional education and counseling to support their decision-making around colonoscopy.

Awareness of colonoscopy as a screening method for colorectal cancer and its uptake in Spain

The objective of this study was to describe awareness levels of colonoscopy as a screening procedure for colorectal cancer (CRC), to study its uptake and analyze possible associated factors in Spain. This was a cross-sectional study using data from the Oncobarómetro survey, carried out by face-to-face interviews with a representative national sample of the Spanish population aged 18 years and older. Awareness was assessed using the following questions: 'Do you know of any examination procedures or medical technique used to detect cancer?' and 'I'm going to list some screening procedures (including colonoscopy) to see if you know of them as a cancer screening test or whether this is the first time you have heard of them'. To evaluate colonoscopy uptake, participants were asked whether they had undergone a colonoscopy in the past 2 years. The independent variables included sociodemographic, socioeconomic, and health-related factors. 65.7% of the study population was aware of colonoscopy as a screening tool. Individuals from lower socioeconomic groups or those who only had primary education showed a lower level of awareness. 12.8% of participants had undergone a colonoscopy in the past 2 years. This number increased to 45% in the Spanish Autonomous Communities, where screening programs are in place. Colonoscopy screening rates are 10.28 times higher among those who had fecal occult blood testing during the previous 2 years. There is an inverse relationship between social inequality and both awareness and uptake of colonoscopy. Consequently, for screening to be more effective, interventions that reduce barriers to access for target populations should be implemented.

Determinants of variations in self-reported barriers to colonoscopy among uninsured patients in a primary care setting.

Colorectal cancer (CRC) is the third most common type of cancer among both males and females in the United States and the second leading cause of cancer-related deaths. Although largely preventable through screening, early detection and removal of polyps, screening rates are considered sub-optimal. Perceived barriers to screening have been reported to influence screening rates. This paper examines variations in the extent to which uninsured patients identified barriers to CRC screening using colonoscopy based on race/ethnicity, educational attainment, age, gender, marital status and prior colonoscopy. Multivariate analyses showed that compared to Caucasians, African Americans had an increased likelihood of identifying lack of transportation as a barrier [odds ratio (OR) 2.68; 95 % confidence interval (CI) 1.35-5.32] while Hispanics were more likely to identify fear of finding cancer as a barrier (OR 2.09; 95 % CI 1.19-3.66). Compared to those with more than a high school education, there was increased likelihood of identifying lack of knowledge as a barrier among individuals with high school education (OR 3.51; 95 % CI 1.94-6.36) or less than a high school education (OR 2.16; 95 % CI 1.04-4.50). Our findings suggest that strategies aimed at increasing colonoscopy screening rates among underserved populations should take into consideration race/ethnicity, educational attainment, age, and prior colonoscopy experience when developing education and outreach plans to reduce barriers to colonoscopy.

Culturally Targeted Patient Navigation for Increasing African Americans' Adherence to Screening Colonoscopy: A Randomized Clinical Trial

Patient navigation has been an effective intervention to increase cancer screening rates. This study focuses on predicting outcomes of screening colonoscopy for colorectal cancer among African Americans using different patient navigation formats. In a randomized clinical trial, patients more than 50 years of age without significant comorbidities were randomized into three navigation groups: peer-patient navigation (n = 181), pro-patient navigation (n = 123), and standard (n = 46). Pro-patient navigations were health care professionals who conducted culturally targeted navigation, whereas peer-patient navigations were community members trained in patient navigation who also discussed their personal experiences with screening colonoscopy. Two assessments gathered sociodemographic, medical, and intrapersonal information. Screening colonoscopy completion rate was 75.7% across all groups with no significant differences in completion between the three study arms. Annual income more than $10,000 was an independent predictor of screening colonoscopy adherence. Unexpectedly, low social influence also predicted screening colonoscopy completion. In an urban African American population, patient navigation was effective in increasing screening colonoscopy rates to 15% above the national average, regardless of patient navigation type or content. Because patient navigation successfully increases colonoscopy adherence, cultural targeting may not be necessary in some populations.

Age-based and Sex-based Disparities in Screening Colonoscopy Use Among Medicare Beneficiaries

The use of screening colonoscopy among older persons is controversial due to variability in life expectancy and sex-based differences in colorectal cancer incidence. We assessed the relation between sex, age, and receipt of screening colonoscopy overall and within strata of life expectancy. We used Medicare data to identify beneficiaries during the years 2001 to 2005 who had not undergone a colonoscopy in the prior 3 years. Medicare claims were used to identify screening colonoscopy use; life expectancy was estimated using a life table approach. We used Poisson regression to examine sex and age differences in screening colonoscopy, adjusted for patient demographic characteristics. Our sample consisted of 161,229 patients (61.9% female; mean age 76.9 y). The screening colonoscopy rates for females and males were 16.9 and 24.4 screening colonoscopies per 1000 person-years, respectively (P<0.001). The screening colonoscopy rate was highest for patients with the longest life expectancy (10 to 15 y: 27.2 screening colonoscopies per 1000 person-years) compared with 3.4 per 1000 person-years in the life expectancy <5-year group. Within specific life expectancy categories, older patients had significantly lower screening rates; in the 10- to 15-year life expectancy category, patients 75 to 79 years old had a lower rate (21.9 screening colonoscopies per 1000 person-years) than patients 68 to 69 years old (34.1 screening colonoscopies per 1000 person-years; P<0.001). In a large cohort of Medicare beneficiaries, there was evidence of screening colonoscopy use even among patients with a short life expectancy. After accounting for life expectancy, females and older persons were less likely to undergo screening colonoscopy.