Interactions of Multiple Chronic Conditions and Sludge on Treatment Burden and Delayed/Skipped Colorectal Cancer Screenings

Context Colorectal cancer (CRC) is a leading cause of cancer death in the US but is highly preventable with screening. 30% of eligible adults do not receive CRC screening, and disparities exist among those with multiple chronic conditions (MCC, having more than one diagnosed chronic health condition that require ongoing medical care). Sludge, a behavioral economics concept describing administrative frictions or burdens, is a health system factor that could exacerbate these disparities. Treatment burden, the impact of receiving healthcare on well-being, is associated with negative outcomes, including reduced completion of preventive services, like CRC screening.

Objective Evaluate the impact of MCC status and sludge in the CRC screening process on treatment burden and delayed/skipped screenings.

Study Design/Analysis Cross-sectional survey. Using regression analyses, we evaluated the relationship of sludge and MCC status on treatment burden and on delayed/skipped screenings.

Setting Regional health system in southwest Virginia.

Population Studied Adults who completed or were referred for CRC screening within the past year.

Instrument Electronic survey to assess sludge encountered in the CRC screening process (0-100 visual analog scale for five sludge types), treatment burden (Treatment Burden Questionnaire), and whether screening was delayed/skipped. We used ICD-10 codes from patient records and the CMS Chronic Conditions algorithm to categorize MCC status.

Outcome Measures Independent variables: MCC status (none, Physical, Mental, Physical+Mental); sludge score. Dependent variables: treatment burden; delayed/skipped screenings.

Results Among 241 participants (64% female, mean age 59), 31.1% had no MCC and 45.6%, 0.8%, 22.4% had MCC(P), MCC(M), and MCC(P+M), respectively. Median sludge score was 63 (16-153), and median TBQ score was 18 (8-37). 29.5% of participants reported delayed/skipped screenings. The MCC(P+M) group was less likely to delay/skip their screening as sludge increased (ß=-2.01, p=0.04). Sludge was positively associated with burden (t(239)=4.9, p<0.001) and delayed/skipped screenings (ß=99.04, p<0.001). No interaction was found between MCC status and sludge.

Conclusions Our findings suggest that sludge in the CRC screening process increases treatment burden similarly in patients of any MCC status. However, despite increased sludge, having both physical and mental MCC decreases the likelihood of delaying/skipping CRC screening.