The Problem

A fecal immunochemical test (FIT) non-invasively tests for colorectal cancer (CRC). FITs help identify patients in need of diagnostic colonoscopies, but follow-up care may be difficult for vulnerable patient populations to carry out, which exacerbates their susceptibility to CRC. FITs generally remain underutilized, especially among racial/ethnic minority and low-income populations, which makes these groups disproportionately susceptible to CRC risk.

At ASCENT, we investigated rates of colonoscopy completion after a positive FIT and obstacles to colonoscopy completion from 2012 to 2015 across the San Francisco Health Network (SFHN), an integrated safety-net health system. We summarize our findings below.

Colonoscopy Completion Rate

In a diverse cohort of 2,238 patients, 1,245 (55.6%) completed a colonoscopy within 1 year of a positive FIT test. We conducted a chart review of a random sample of this cohort to identify system and patient factors associated with incomplete follow-up.

Barriers to Colonoscopy Completion

Documented Reasons for Missing a Colonoscopy

Researchers discovered that some patients may not be counseled on the importance of colonoscopies. For example, some patients who missed their gastroenterology (GI) appointment after a provider referral lacked documentation of counseling of their positive FIT result on their medical record, challenging the follow-up procedure. Moreover, patients may lack documentation of a recommended colonoscopy because they completed it at an outside facility, declined the colonoscopy, or a provider erroneously documented a positive FIT as negative.

Further, inappropriate CRC screening contributes to colonoscopy incompletion. For example, researchers found that ten percent of patients who were referred to the SFHN GI referral unit completed a FIT in error.

Patient Characteristics Related to Colonoscopy Completion

Married, female, Asian, and non-English speaking patients were more likely to complete a colonoscopy within 1 year of a positive FIT. Patients who were never referred or who missed their referral appointment after an abnormal FIT result were more likely to have documented comorbidities, (e.g. cardiovascular disease), experience social issues (e.g. unstable housing), be hospitalized after an abnormal FIT, and use chronic opiates.

Future Directions

There is a need to re-develop workflows and incorporate low-cost communication tools to maintain adequate correspondence with patients who have abnormal FIT results and are in need of diagnostic colonoscopies. For example, an assigned nurse or medical assistant who can coordinate follow-up care or using text-message reminders could increase colonoscopy completions.

Further, we can minimize inappropriate CRC screening and improve health information technology by making prior lab results more visible and accessible in the electronic health record, and by creating a periodic automated system that shares updates on a patient’s abnormal test result with the appropriate providers.

ASCENT research highlights the importance of minimizing inappropriate screening of CRC, documenting counseling of abnormal test results, and developing context-specific clinical programs addressing abnormal test results to help ensure the proper management of abnormal FIT results.

Sources:

Fecal Immunochemical Test (FIT). MedlinePlus.gov. Updated 05 September 2017. https://medlineplus.gov/ency/patientinstructions/000704.htm

Issaka, R. B., Singh, M. H., Oshima, S. M., Laleau, V. J., Rachocki, C. D., Chen, E. H., ... & Somsouk, M. (2017). Inadequate Utilization of Diagnostic Colonoscopy Following Abnormal FIT Results in an Integrated Safety-Net System. The American Journal of Gastroenterology, 112(2), 375-382.