Uptake Of Screening Colonoscopy Research Articles

Effect of Behavioral Interventions on the Uptake of Colonoscopy for Colorectal Cancer Screening: A Systematic Review and Meta-Analysis.

Screening decreases colorectal cancer incidence and mortality, but uptake in the United States remains suboptimal. Prior studies have investigated the effect of various interventions on overall colorectal cancer screening and stool-based testing, but the effect on colonoscopy-the predominant screening test in the United States-has not been fully examined. We performed a systematic review and meta-analysis to assess the effect of behavioral interventions on screening colonoscopy uptake. We searched PubMed, Embase, and Cochrane databases through January 2022 for controlled trials that assessed the effect of behavioral interventions on screening colonoscopy uptake. All titles, abstracts, and articles were screened by at least 2 independent reviewers. Odds ratios were extracted from the original article or calculated from the raw data. The primary outcome was the relative increase in screening colonoscopy completion with any behavioral intervention. We performed random-effects meta-analysis, with subgroup analysis by type of intervention. A total of 25 studies with 30 behavioral interventions were analyzed. The most common interventions were patient navigation (n = 11) and multicomponent interventions (n = 6). Overall, behavioral interventions increased colonoscopy completion by 54% compared with controls (odds ratio [OR] 1.54, 95% confidence interval [CI] 1.26-1.88). Patient navigation (OR 1.78, 95% CI 1.35-2.34) and multicomponent interventions (OR 1.84, 95% CI 1.17-2.89) had the strongest effect on colonoscopy completion among interventions examined in multiple studies. Significant heterogeneity was observed both overall and by intervention type. There was no evidence of publication bias. Behavioral interventions increase screening colonoscopy completion and should be adopted in clinical practice. In particular, patient navigation and multicomponent interventions are the best-studied and most effective interventions.

Factors Associated with Up-to-Date Colonoscopy Use Among Puerto Ricans in New York City, 2003-2016.

Colorectal cancer is the second leading cause of cancer death among Hispanic Americans. Puerto Ricans are the second largest Hispanic subgroup in the USA and the largest in New York City, but little is known about predictors of colorectal cancer screening uptake in this population. We used the New York City Community Health Survey, a population-based telephone survey, to investigate predictors of up-to-date colonoscopy use over time among Puerto Ricans aged ≥ 50years in NYC. We assessed the association between sociodemographic and medical factors and up-to-date colonoscopy use (defined as colonoscopy within the last 10years) using univariable and multivariable logistic regression over six time periods: 2003-2005, 2006-2008, 2009-2010, 2011-2012, 2013-2014, and 2015-2016. On multivariable analysis, age ≥ 65years (OR 1.64-1.93 over three periods) and influenza vaccination (OR 1.86-2.17 over five periods) were the two factors most consistently associated with up-to-date colonoscopy use. Individuals without a primary care provider (OR 0.38-0.50 over three periods) and who did not exercise (OR 0.49-0.52 over two periods) were significantly less likely to have an up-to-date colonoscopy. Older age, influenza vaccination, having a primary care provider, and exercise are independent predictors of up-to-date colonoscopy use among Puerto Ricans in NYC. Interventions to improve screening colonoscopy uptake among Puerto Ricans should be targeted to those aged 50-64years and who do not have a primary care provider.

Area-Based Socioeconomic Inequalities in Colorectal Cancer Survival in Germany: Investigation Based on Population-Based Clinical Cancer Registration

Background: Socioeconomic inequalities in colorectal cancer survival have been observed in many countries. To overcome these inequalities, the underlying reasons must be disclosed.Methods: Using data from three population-based clinical cancer registries in Germany, we investigated whether associations between area-based socioeconomic deprivation and survival after colorectal cancer depended on patient-, tumor- or treatment-related factors. Patients with a diagnosis of colorectal cancer in 2000–2015 were assigned to one of five deprivation groups according to the municipality of the place of residence using the German Index of Multiple Deprivation. Cox proportional hazards regression models with various levels of adjustment and stratifications were applied.Results: Among 38,130 patients, overall 5-year survival was 4.8% units lower in the most compared to the least deprived areas. Survival disparities were strongest in younger patients, in rectal cancer patients, in stage I cancer, in the latest period, and with longer follow-up. Disparities persisted after adjustment for stage, utilization of surgery and screening colonoscopy uptake rates. They were mostly still present when restricting to patients receiving treatment according to guidelines.Conclusion: We observed socioeconomic inequalities in colorectal cancer survival in Germany. Further studies accounting for potential differences in non-cancer mortality and exploring treatment patterns in detail are needed.

332 Effect of Behavioral Interventions on the Uptake of Screening Colonoscopy: A Systematic Review and Meta-Analysis

INTRODUCTION: Screening decreases colorectal cancer (CRC) incidence and mortality, but uptake in the United States remains suboptimal at 62%. Prior studies have investigated the effect of various interventions on overall CRC screening and stool-based testing, but the effect on colonoscopy—the predominant screening test in the US—has not been fully examined. We performed a systematic review and meta-analysis to assess the effect of behavioral interventions on screening colonoscopy uptake. METHODS: We searched PubMed, EMBASE, and Cochrane databases through June 2018 for controlled trials that assessed the effect of behavioral interventions on screening colonoscopy rates. Our search yielded a total of 6,952 titles. All abstracts and articles were screened by at least two independent reviewers and 54 manuscripts were selected for review. Relative risk estimates were extracted from the original article or calculated from the raw data. The primary outcome was the relative increase in screening colonoscopy completion with any behavioral intervention. Subgroup analysis by type of intervention was also performed. Random effects meta-analysis was performed using Stata. RESULTS: A total of 21 studies with 24 behavioral interventions were analyzed. The most common interventions were patient navigation (n = 8), a combination of multiple interventions (n = 7), and educational interventions (n = 4). Overall, behavioral interventions increased colonoscopy completion by 58% compared to controls (OR 1.58, 95% CI 1.33-1.88, Figure). Patient navigation (OR 1.80, 95% CI 1.22-2.67) and multiple interventions (OR 1.70, 95% CI 1.15-2.50) had the strongest effect on colonoscopy completion. Significant heterogeneity was observed both overall and by intervention type, which may be attributed to differences in study setting and control group selection. CONCLUSION: Behavioral interventions increase screening colonoscopy completion and should be considered in clinical practice. In particular, patient navigation and multiple interventions are the best-studied and most effective interventions.

The effect of gender-specific invitation letters on utilization ofcolorectal cancer screening.

Colorectal cancer (CRC) screening can effectively reduce cancer-associated mortality. In Germany, individuals over the age of 50 or 55 have access to CRC screening services. However, utilization rates are persistently low, particular in the male population. This observational study investigates the effect of standard versus gender-specific invitation letters on utilization of CRC screening services. We analyzed utilization rates of individuals who were insured by a large health insurance fund in Bavaria, Germany. Persons who became eligible for CRC screening received a standard (2013-2014) or a gender-specific invitation letter (2015-2016). We compared utilization rates within 6 months after receipt of the invitation letter using billing codes of the health insurance fund. Invitation letters were sent to 49 535 individuals, of which 48.8 % were gender-specific. The overall utilization rate did not differ between recipients of the standard versus gender-specific invitation letter (11.6 % vs 11.1 %; RR: 0.97 [0.92-1.02], p = 0.19). However, uptake of screening colonoscopy was significantly higher among recipients of gender-specific invitations (2.9 % vs 3.5 %; RR: 1.21 [1.04-1.39], p = 0.01), whereas utilization of fecal occult blood tests declined (10.4 % vs 9.7 %; RR: 0.93 [0.88-0.99], p = 0.016). Gender-specific design of invitation letters can modify the patients' preference for specific CRC screening services and increase the acceptance of screening colonoscopy.

Changes in colorectal cancer screening use after introduction of alternative screening offer in Germany: Prospective cohort study.

In October 2002, screening colonoscopy was added to the German colorectal cancer (CRC) screening program as an alternative to fecal occult blood test (FOBT). We aimed to evaluate the change in CRC screening use after introduction of the dual screening offer and to assess determinants of screening use. Data were drawn from a population-based cohort study initiated during 2000-2002 in Germany (n = 5,845, age range at recruitment: 50-75 years). We conducted both cross-sectional and longitudinal analyses to obtain uptake rates of CRC screening based on four waves of data. Age-group specific proportions of participants having had FOBT within 2 years remained essentially unchanged at 61-67% between 2000 and 2002 (1st wave) and 2005-2007 (3rd wave). The proportions of participants having undergone screening colonoscopy within 10 years increased from 23-29% to 46-57%, leading to a substantial overall increase in being up-to-date with CRC screening from 66-68% to 77-80%. In 2008-2010 (4th wave), FOBT use declined and colonoscopy use continued to increase. Obesity was significantly associated with lower prevalence of being up-to-date with FOBT (odds ratio [OR] at 8-year follow-up 0.68; 95% confidence interval [CI], 0.58-0.80) and screening colonoscopy (OR, 0.73; 95% CI, 0.62-0.86). Also, smokers were less likely to have ever used FOBT (OR, 0.54; 95% CI, 0.40-0.75) or colonoscopy (OR, 0.75; 95% CI, 0.63-0.90) compared to nonsmokers. After the introduction of dual screening offer, the overall adherence to CRC screening steeply increased, mainly due to an increase in screening colonoscopy uptake. Screening tests kept being underused by obese people and smokers who are at elevated CRC risk.

Comparison of the Uptake of Screening Colonoscopy between Physicians and the General Population in Greece

Aim: To evaluate the uptake of screening colonoscopy among physicians as compared to the general population. Methods: Asymptomatic physicians, aged 45–67 years, at average risk for colorectal cancer (CRC), working in the participating National Health System hospitals were asked to complete a questionnaire regarding the uptake of screening colonoscopy. The results were compared to those in a background healthy population, aged 50–75 years, inhabitants of a Greek county, who were offered a free access to a screening colonoscopy program for CRC. High-risk adenomas were those ≥10 mm in diameter or any adenoma, regardless of size, with villous histology or high-grade dysplasia. Results: Overall, 267 of 782 physicians and 402 of 6,534 nonphysicians underwent a screening colonoscopy (uptake rates 34.2 and 6.2% respectively, p = 0.00001). Screening colonoscopy has yielded 4 adenocarcinomas (1.6%), 14 high-risk adenomas (5.5%), and 61 low-risk adenomas (25.7%) in the physicians’ group. Corresponding figures in the nonphysician arm were 4 (1), 26 (6.5), and 107 (26.6%), respectively. The main reason among physicians for nonadherence was indifference/negligence (n = 213). Conclusion: The proportion of physicians undergoing screening colonoscopy for CRC is significantly higher compared to the general population; however, it does remain suboptimal.

Motivational interviewing and screening colonoscopy in high-risk individuals. A randomized controlled trial

ObjectiveTo measure the impact of motivational interviewing (MI) on cancer knowledge and screening practice among first degree relatives (FDRs) of patients with colon cancer. MethodsThis randomized controlled trial targeted patients with colon cancer first to recruit their possible FDRs. Digit randomization of the eligible index patients into intervention or control groups resulted in allocating their belonging FDRs to the same study arm. FDRs (n = 120) in intervention arm received MI counseling on phone by a trained oncology nurse and FDRs (n = 120) in control group received standard generic information by a physician on phone. Primary outcome was the rate of documented colonoscopy in FDRs within six months after the baseline. ResultsA total of 227 FDRs were followed up, 115 in the intervention and 112 in the control group. At follow-up, the uptake of screening colonoscopy in the intervention group was 83.5% versus 48.2% in controls (crude odds ratio, 5.4; 95% confidence interval, 2.9–10.0, P < .001). ConclusionThis was the first randomized controlled trial in Iran that confirmed the efficaciousness of a phone-based MI counseling in improving colonoscopy uptake among family members of patients with colon cancer. Practice implicationsPhone-based motivational counseling that involves trained nurses or health providers seems to be feasible approach in Iran health system and enhances screening for colon cancer.

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

Mo1110 A Systematic Review of Patient Provider, and System Barriers to Colorectal Cancer Screening With Colonoscopy in African-Americans

Introduction: African-Americans (AAs) are 20% less likely than Caucasians to undergo appropriate colorectal cancer (CRC) screening. The group also carries the greatest burden of disease, as evidenced by the highest: 1) incidence of CRC of any ethnic group; 2) CRC mortality rate; 3) prevalence of polyps at screening colonoscopy; 4) incidence of high-grade dysplasia at age ,50; and 5) incidence of advanced stage at disease presentation. While studies have explored barriers to uptake for screening colonoscopy among AAs, existing literature lacks a comprehensive conceptual framework that synthesizes the contributing patient, provider, and system factors. We sought to systematically review the literature to inform a conceptual framework governing all barriers to colonoscopic screening in AAs. Methods: We conducted a systematic review of Medline and Cochrane databases for studies addressing barriers to colonoscopic CRC screening. Search results were reviewed manually and included if they addressed barriers to uptake of screening colonoscopy, included AAs in the U.S, and were published in English between 1/1/90 and 11/1/12. We then employed a modified Andersen Behavioral Model of Health Service Use as a conceptual framework to construct a model for uptake for screening colonoscopy among AAs in the U.S. ( Table). Results: We identified and reviewed 409 abstracts by two authors; 127 were included in the full-text review process. Of these studies, 34 met criteria for inclusion. 20 (59%) studies presented patient-level barriers to screening uptake, 13 (38%) addressed provider-level barriers, and 8 (24%) presented system-level factors. 16 (47%) studies reported rates of colonoscopy uptake for AAs, which ranged from 14% to 65%. Prominent patient-level barriers were low education level, lack of knowledge about CRC screening, fear of cancer diagnosis, anxiety about procedure discomfort, self-perception of low cancer risk, and direct and indirect costs. Provider-level factors included knowledge deficits about guidelines and lack of screening recommendation. System-level factors included lack of insurance coverage, poor access to care, insufficient time with primary care physicians, inaccessibility of specialist services, absence of reminder systems, and insufficient reimbursement for discussing screening. Conclusions: We identified multiple, modifiable patient, provider, and system-level barriers to CRC screening among average-risk AAs. Heeding these barriers, future interventions should target patient knowledge about the efficacy of colonoscopy screening for preventing CRC, physician knowledge about screening guidelines for AAs, and access to healthcare services. Using focused interventions at the level of the patient, provider, and healthcare system, we may reduce the morbidity and mortality from CRC in this high-risk, under-screened population. Patient, Provider, and System-level Barriers to Colorectal Cancer Screening Among AfricanAmericans. Based on a modified Andersen Model of Health Services Use.

PTU-256 Optimising bowel screening colonoscopy uptake with nurse-led telephone assessment clinics

IntroductionBowel Screening Wales utilises nurse-led telephone assessments pre-colonoscopy for screening participants following a positive faecal occult blood test (FOBt) result. This approach has been shown to optimise colonoscopy uptake.MethodsA literature...

Patients’ experiences and reported barriers to colonoscopy in the screening context—A systematic review of the literature

ObjectiveA systematic review of the literature was conducted to characterise patients’ own experience of colonoscopy in the screening context. MethodsA search strategy was applied in MEDLINE, EMBASE and PSYCHinfo (1996–2009). Thematic analysis and narrative summary techniques were used. ResultsFifty-six studies met eligibility criteria and were included in the analysis. Seven studies examined patients’ views after having colonoscopy. Forty-seven studies addressed patient-reported barriers to an anticipated primary colonoscopy. Most patients perceived the laxative bowel preparation to be the most burdensome part of colonoscopy. Other reported difficulties included anxiety, anticipation of pain, feelings of embarrassment and vulnerability. Inadequate knowledge and fear of finding cancer were identified as obstacles to the uptake of screening colonoscopy. Physician endorsement, having a family history, knowing someone with cancer, and perceived accuracy of the test were incentives to having a colonoscopy. Two studies focused on colonoscopy after faecal occult blood screening. Similar procedural, personal, and practical concerns were reported. ConclusionsBowel preparation, lack of awareness of the importance of screening, and feelings of vulnerability in women are all significant barriers to screening colonoscopy. Practice implicationsPatient reported obstacles and barriers to screening colonoscopy needs to be addressed to improve adherence.

Is there a place for sedationless colonoscopy?

Usedated colonoscopy is routinely available in many parts of the world. In the US, only educated professionals appear to be knowledgeable enough to request the unsedated option. Colonoscopists have also been willing to perform unsedated colonoscopy when a patient presents without an escort after undergoing bowel purge preparation. While the actual side-effects of sedation are minimal, the escort requirement and time burden of sedation are barriers to the uptake of screening colonoscopy in the US. The recent trend of deep sedation with propofol for screening colonoscopy increases the efficiency of the colonoscopists at significant costs (e.g. anesthetist reimbursement). The options of as needed and on demand sedation permit patients to complete colonoscopy without sedation. The latter appears to be potentially less coercive. Nurses with experience in the unsedated options recognize the benefit of the quick turn-around of the examination room and shortened occupancy of the recovery area. Discharge planning can be optimized due to absence of amnesia. Patients completing unsedated colonoscopy have given their endorsement of the options. Pain and discomfort continue to limit the success rate of cecal intubation to about 80%. A recently described water method (warm water infusion in lieu of air insufflation combined with removal of all residual colonic air by suction and residual feces by water exchange) has the potential of decreasing procedural discomfort and enhancing cecal intubation in unsedated colonoscopy. The availability of the novel water method assures colonoscopists that high success rate of cecal intubation can be achieved in the unsedated patients.

Patients’ experiences and reported barriers to screening colonoscopy: A systematic review

1537 Background: Colonoscopy is a component of most colorectal screening programs, as a primary test or as follow-up to an abnormal FOB test. Little is known about why some patients do not comply with colonoscopy after being referred. Methods: A search strategy using three themes of screening, colonoscopy, and patient acceptance was developed and used in MEDLINE, EMBASE and PSYCHinfo (1996–2008). Retrieved citations were assessed for eligibility by two reviewers using prespecified criteria. A qualitative synthesis was conducted. Results: From an initial 3,174 studies, 264 were identified as potentially eligible for review. After full text assessment, 64 studies met eligibility criteria and were included in the final analysis. Six studies examined the experience of a primary colonoscopy by eliciting patients’ views soon after they had the test. Fifty-six studies addressed patient-reported concerns and barriers to an anticipated primary colonoscopy. Most patients perceived the laxative bowel preparation to be the most burdensome part and the greatest barrier to colonoscopy. Other reported difficulties included anxiety and anticipation of pain. Feelings of embarrassment and vulnerability occurred, particularly in women, and also acted as barriers to adherence. Inadequate knowledge about screening was common and was identified as an obstacle to the uptake of screening colonoscopy as was fear of finding cancer. Physician endorsement, having a family history, knowing someone with cancer, and perceived accuracy of the test were incentives to having a colonoscopy. The most common reported practical barriers were inconvenience, transportation, scheduling, and cost. Only two studies focused on colonoscopy as a secondary procedure in the screening context. Similar procedural, personal, and practical concerns were reported by patients in this setting. Conclusions: Bowel preparation, lack of awareness of the importance of screening, and feelings of vulnerability in women are all significant barriers to colonoscopy in the screening context. These obstacles need to be addressed, and further research undertaken on barriers to second line colonoscopy. No significant financial relationships to disclose.

A Program to Enhance Completion of Screening Colonoscopy Among Urban Minorities

Although colonoscopy is becoming the preferred screening test for colorectal cancer, screening rates, particularly among minorities, are low. Little is known about the uptake of screening colonoscopy or the factors that predict colonoscopy completion among minorities. This study investigated the use of patient navigation within an open-access referral system and its effects on colonoscopy completion rates among urban minorities. This was a cohort study that took place at a teaching hospital in New York. Participants were mostly African Americans and Hispanics directly referred for screening colonoscopy by primary care clinics from November 2003 to May 2006. Once referred, a bilingual Hispanic female patient navigator facilitated the colonoscopy completion. Completion rates, demographic factors associated with completing colonoscopy, endoscopic findings, and patient satisfaction were analyzed. Of 1169 referrals, 688 patients qualified for and 532 underwent navigation. Two thirds (66%) of navigated patients completed screening colonoscopies, 16% had adenomas, and only 5% had inadequate bowel preps. Women were 1.31 times more likely to complete the colonoscopy than men (P = .014). Hispanics were 1.67 times more likely to complete the colonoscopy than African Americans (P = .013). Hispanic women were 1.50 times more likely to complete the colonoscopy than Hispanic men (P = .009). Patient satisfaction was 98% overall, with 66% reporting that they definitely or probably would not have completed their colonoscopy without navigation. By using a patient navigator, the majority of urban minorities successfully completed their colonoscopies, clinically significant pathology was detected, and patient satisfaction was enhanced. This approach may help increase adherence with screening colonoscopy efforts in other clinical settings.