Original article
Alimentary tract
Barriers to Follow-up Colonoscopies for Patients With Positive Results From Fecal Immunochemical Tests During Colorectal Cancer Screening

https://doi.org/10.1016/j.cgh.2018.05.022Get rights and content

Background & Aims

Colorectal cancer is common yet largely preventable. The fecal immunochemical test (FIT) is a highly recommended screening method, but patients with positive results must receive a follow-up colonoscopy to determine if they have precancerous or cancerous lesions. We characterized colonoscopic follow-up evaluations and reasons for lack of follow-up in a Veterans Affairs (VA) cohort.

Methods

We conducted a retrospective cross-sectional analysis of patients 50 to 75 years old with a positive FIT result from January 1, 2014, through May 31, 2016, in a network of 12 VAs sites in southern California. We determined the proportion of patients who received a follow-up colonoscopy, median time to colonoscopy, and colonoscopy findings. For patients who did not undergo colonoscopy, we determined the documented reason for lack of colonoscopy and factors associated with declining the colonoscopy examination.

Results

Of the 10,635 FITs performed, 916 (8.6%) produced positive results; 569 of these (62.1%) were followed by colonoscopy. The median time to colonoscopy after a positive FIT result was 83 days (interquartile range, 54–145 d), which did not vary between veterans who received a colonoscopy at a VA facility (81 d; interquartile range, 52–143 d) vs a non-VA site (87 d; interquartile range, 60–154 d) (P = .2). For the 347 veterans (37.9%) who did not undergo follow-up colonoscopy, the reasons were patient-related (49.3%), provider-related (16.4%), system-related (12.1%), or multifactorial (22.2%). Overall, patient decline of colonoscopy (35.2%) was the most common reason.

Conclusions

In a cohort of veterans with positive results from FITs during CRC screening, reasons for lack of follow-up colonoscopy varied and included patient, provider, and system factors. These findings can be used to reduce barriers to follow-up colonoscopy and to address system-level challenges in scheduling and attrition for colonoscopy.

Section snippets

Description of Colorectal Cancer Screening Process

The study setting is an integrated network of 12 VA sites in southern California. The majority of patients are screened by either colonoscopy or FIT. For FIT screening, patients receive the Polymedco OC-Auto Micro 80 iFOB FIT kit (Polymedco Inc, Cortland Manor, NY) from PCPs or registered nurses during routine PCP visits. FIT samples are processed only if returned within 14 days of the stool deposit, and the quantitative cut-off value for a positive result is 20 μg hemoglobin/g stool. After a

Descriptive Characteristics of the Sample

During the study period, 10,635 FITs were performed and 916 (8.6%) were positive. The mean age of the cohort was 63.9 years, and 95.9% of patients were male. The cohort was racially/ethnically diverse, with 22.4% blacks and 12.1% Hispanics. In all, 569 (62.1%) patients completed a diagnostic colonoscopy within 6 months, and 73% were performed at the VA. There were no significant differences in uptake of colonoscopy by demographic or clinical factors in bivariate analyses (Table 1).

Time to Colonoscopy Referral and Time to Colonoscopy

Most patients

Discussion

We found that more than one third of Veterans with a positive FIT in a large and diverse VA health care network did not undergo a diagnostic colonoscopy. We also identified several patient-, provider-, and system-level reasons for this lack of follow-up evaluation. Our findings are consistent with prior studies that have suggested a 40% to 60% colonoscopy follow-up rate after a positive FIT in VA and non-VA populations.6, 9, 14 In addition, our findings mirror those of other studies in

Acknowledgments

The authors would like to thank Mark Reid for his assistance with preliminary statistical analyses.

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Conflicts of interest The authors disclose no conflicts.

Funding Supported by a Veterans Affairs Health Services Research and Development Senior Research Career Scientist Award (project RCS 05-195) (E.M.Y.); support for analyses was provided by the VA HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System (project CIN 13-417); and also supported by the VA Greater Los Angeles Healthcare System Department of Medicine and Division of Gastroenterology (F.M.). The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the US government.

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