System Dynamics of Supporting CRC Screening Completion and Follow-Up
This diagram visualizes the complex interactions and factors influencing clinics’ ability to increase routine CRC screening completion and ensure high-quality exams are performed. This causal loop diagram illustrates the various components that clinics must navigate to successfully meet CRC screening metrics and goals.
Understanding the diagram:
- S (Same): Arrows marked with “S” indicate that the two connected variables move in the same direction. For example, if one variable increases, the other also increases.
- O (Opposite): Arrows marked with “O” suggest that the variables move in opposite directions. If one variable increases, the other decreases.
- Solid Lines: These lines represent direct relationships or influences between variables.
- Dotted Lines: Dotted lines indicate indirect relationships or feedback loops that may require additional steps to influence the connected variables.
The diagram serves as a roadmap for understanding how various factors interact to influence clinics’ ability to adhere to CRC screening guidelines among screening-eligible patients. By examining these loops, we can gain insights into the dynamics that clinics face in supporting CRC screening completion and effectively preventing cancer cases in their patient populations.
Cited references for this diagram
Challenges included insufficient capacity in existing systems to track distribution and return of FIT kits and reluctance from clinicians to support use of a screening tool other than colonoscopy.
Arena L, Soloe C, Schlueter D, Ferriola-Bruckenstein K, DeGroff A, Tangka F, Hoover S, Melillo S, Subramanian S. Modifications in Primary Care Clinics to Continue Colorectal Cancer Screening Promotion During the COVID-19 Pandemic. J Community Health. 2023 Feb;48(1):113-126. doi: 10.1007/s10900-022-01154-9. Epub 2022 Oct 29. PMID: 36308666; PMCID: PMC9617236.
Third, support from clinic leadership is essential for continuing CRC screening promotion efforts and exploring innovative solutions to emergent challenges, especially when faced with limited clinic resources and staff capacity.[[42, 59]]
Arena L, Soloe C, Schlueter D, Ferriola-Bruckenstein K, DeGroff A, Tangka F, Hoover S, Melillo S, Subramanian S. Modifications in Primary Care Clinics to Continue Colorectal Cancer Screening Promotion During the COVID-19 Pandemic. J Community Health. 2023 Feb;48(1):113-126. doi: 10.1007/s10900-022-01154-9. Epub 2022 Oct 29. PMID: 36308666; PMCID: PMC9617236.
Consistent with previous studies,[[42]] we found that mailed FIT outreach is challenging without adequate staff capacity and systems for tracking FIT kit dissemination and return and follow-up to ensure patients with positive test results complete a timely colonoscopy. Developing stand-alone tracking databases and/or increasing use of automated systems embedded within clinic EMRs may improve FIT kit tracking and facilitate dissemination of patient reminders to complete and return their kits.[[42]]
Arena L, Soloe C, Schlueter D, Ferriola-Bruckenstein K, DeGroff A, Tangka F, Hoover S, Melillo S, Subramanian S. Modifications in Primary Care Clinics to Continue Colorectal Cancer Screening Promotion During the COVID-19 Pandemic. J Community Health. 2023 Feb;48(1):113-126. doi: 10.1007/s10900-022-01154-9. Epub 2022 Oct 29. PMID: 36308666; PMCID: PMC9617236.
With improved tracking and automated reminder systems, mailed FIT kits paired with tailored patient education and clear instructions for completing the test may help primary care clinics catch up on the backlog of missed screenings during the COVID-19 pandemic.
Arena L, Soloe C, Schlueter D, Ferriola-Bruckenstein K, DeGroff A, Tangka F, Hoover S, Melillo S, Subramanian S. Modifications in Primary Care Clinics to Continue Colorectal Cancer Screening Promotion During the COVID-19 Pandemic. J Community Health. 2023 Feb;48(1):113-126. doi: 10.1007/s10900-022-01154-9. Epub 2022 Oct 29. PMID: 36308666; PMCID: PMC9617236.
In these cases, participants noted that clinic champions were essential to fostering clinician and leadership buy-in for using mailed FIT kits as well as supporting improved tracking systems that would reduce burden on staff.
Arena L, Soloe C, Schlueter D, Ferriola-Bruckenstein K, DeGroff A, Tangka F, Hoover S, Melillo S, Subramanian S. Modifications in Primary Care Clinics to Continue Colorectal Cancer Screening Promotion During the COVID-19 Pandemic. J Community Health. 2023 Feb;48(1):113-126. doi: 10.1007/s10900-022-01154-9. Epub 2022 Oct 29. PMID: 36308666; PMCID: PMC9617236.
Increased patient education and engagement emerged as a modification to address challenges around receipt of completed FIT kits that did not adhere to requirements and were, therefore, unusable because they were missing the collection date or received more than 14 days after the sample was collected.
Arena L, Soloe C, Schlueter D, Ferriola-Bruckenstein K, DeGroff A, Tangka F, Hoover S, Melillo S, Subramanian S. Modifications in Primary Care Clinics to Continue Colorectal Cancer Screening Promotion During the COVID-19 Pandemic. J Community Health. 2023 Feb;48(1):113-126. doi: 10.1007/s10900-022-01154-9. Epub 2022 Oct 29. PMID: 36308666; PMCID: PMC9617236.
Participants also reported reluctance among some clinicians to embrace increased use of FIT kits vs. continued promotion of screening colonoscopies, even temporarily[[44–46]] as a challenge.
Arena L, Soloe C, Schlueter D, Ferriola-Bruckenstein K, DeGroff A, Tangka F, Hoover S, Melillo S, Subramanian S. Modifications in Primary Care Clinics to Continue Colorectal Cancer Screening Promotion During the COVID-19 Pandemic. J Community Health. 2023 Feb;48(1):113-126. doi: 10.1007/s10900-022-01154-9. Epub 2022 Oct 29. PMID: 36308666; PMCID: PMC9617236.
Interview respondents discussed increasing use of mailed FIT or other stool-based tests over referrals for screening colonoscopy; using mailed FIT kits, some with labels filled in or self-addressed envelopes to facilitate return; and offering contactless FIT drop-off options.
Arena L, Soloe C, Schlueter D, Ferriola-Bruckenstein K, DeGroff A, Tangka F, Hoover S, Melillo S, Subramanian S. Modifications in Primary Care Clinics to Continue Colorectal Cancer Screening Promotion During the COVID-19 Pandemic. J Community Health. 2023 Feb;48(1):113-126. doi: 10.1007/s10900-022-01154-9. Epub 2022 Oct 29. PMID: 36308666; PMCID: PMC9617236.
Using an iterative approach to qualitative data collection and analysis, our study yielded three validated themes that describe how clinics modified CRC screening promotion efforts during the COVID-19 pandemic: (1) offering mailed FIT kits for CRC screening with mail or drop-off return, (2) increasing the use of patient education and engagement strategies, and (3) increasing the use of or improving automated patient messaging systems.
Arena L, Soloe C, Schlueter D, Ferriola-Bruckenstein K, DeGroff A, Tangka F, Hoover S, Melillo S, Subramanian S. Modifications in Primary Care Clinics to Continue Colorectal Cancer Screening Promotion During the COVID-19 Pandemic. J Community Health. 2023 Feb;48(1):113-126. doi: 10.1007/s10900-022-01154-9. Epub 2022 Oct 29. PMID: 36308666; PMCID: PMC9617236.
During interviews, respondents discussed benefiting from increasing use of automated patient messaging systems while responding to COVID-19 to disseminate CRC screening reminders and establishing or streamlining FIT kit standing orders to reduce burden on heavily strained clinic staff.
Arena L, Soloe C, Schlueter D, Ferriola-Bruckenstein K, DeGroff A, Tangka F, Hoover S, Melillo S, Subramanian S. Modifications in Primary Care Clinics to Continue Colorectal Cancer Screening Promotion During the COVID-19 Pandemic. J Community Health. 2023 Feb;48(1):113-126. doi: 10.1007/s10900-022-01154-9. Epub 2022 Oct 29. PMID: 36308666; PMCID: PMC9617236.
A majority of focus group respondents agreed that increased reliance on automated patient messaging systems to reach patients was a modification implemented by their clinic partners to promote CRC screening during COVID-19.
Arena L, Soloe C, Schlueter D, Ferriola-Bruckenstein K, DeGroff A, Tangka F, Hoover S, Melillo S, Subramanian S. Modifications in Primary Care Clinics to Continue Colorectal Cancer Screening Promotion During the COVID-19 Pandemic. J Community Health. 2023 Feb;48(1):113-126. doi: 10.1007/s10900-022-01154-9. Epub 2022 Oct 29. PMID: 36308666; PMCID: PMC9617236.
For the reluctance to support use of CRC screening tests other than colonoscopy, recipients described the importance of support from clinic champions and framing of messaging to clinic staff to get them on board with using mailed FIT kits to reach more patients, particularly during a time when clinics were facing high rates of staff turnover and patients were not able or willing to come into the clinic.
Arena L, Soloe C, Schlueter D, Ferriola-Bruckenstein K, DeGroff A, Tangka F, Hoover S, Melillo S, Subramanian S. Modifications in Primary Care Clinics to Continue Colorectal Cancer Screening Promotion During the COVID-19 Pandemic. J Community Health. 2023 Feb;48(1):113-126. doi: 10.1007/s10900-022-01154-9. Epub 2022 Oct 29. PMID: 36308666; PMCID: PMC9617236.
This public health emergency served as a catalyst for primary care clinics to adopt mailed FIT outreach as a means to continue promoting CRC screening while addressing patient hesitancy to attend in-person appointments, reducing patient risk for COVID-19 exposure and addressing the issue of postponed or missed non-urgent procedures (including screening colonoscopies) during periods of high infection rates.[[10, 15, 16, 43]]
Arena L, Soloe C, Schlueter D, Ferriola-Bruckenstein K, DeGroff A, Tangka F, Hoover S, Melillo S, Subramanian S. Modifications in Primary Care Clinics to Continue Colorectal Cancer Screening Promotion During the COVID-19 Pandemic. J Community Health. 2023 Feb;48(1):113-126. doi: 10.1007/s10900-022-01154-9. Epub 2022 Oct 29. PMID: 36308666; PMCID: PMC9617236.
Most respondents agreed that their clinic partners increased use of mailed FIT kits with mail or drop off return options and focused on patient education and engagement to promote CRC screening in response to COVID-19.
Arena L, Soloe C, Schlueter D, Ferriola-Bruckenstein K, DeGroff A, Tangka F, Hoover S, Melillo S, Subramanian S. Modifications in Primary Care Clinics to Continue Colorectal Cancer Screening Promotion During the COVID-19 Pandemic. J Community Health. 2023 Feb;48(1):113-126. doi: 10.1007/s10900-022-01154-9. Epub 2022 Oct 29. PMID: 36308666; PMCID: PMC9617236.
Respondents also described the challenge of receiving incomplete or incorrectly completed FIT tests due to patient misunderstanding around instructions to complete FIT testing which could have occurred because of cultural/linguistic barriers or a breakdown in communication when patients do not receive instructions in person.
Arena L, Soloe C, Schlueter D, Ferriola-Bruckenstein K, DeGroff A, Tangka F, Hoover S, Melillo S, Subramanian S. Modifications in Primary Care Clinics to Continue Colorectal Cancer Screening Promotion During the COVID-19 Pandemic. J Community Health. 2023 Feb;48(1):113-126. doi: 10.1007/s10900-022-01154-9. Epub 2022 Oct 29. PMID: 36308666; PMCID: PMC9617236.
Overall, the majority of patient barriers and navigation activities delivered by BCC and CRC PNs were related to personal and cultural factors. Clearly, lack of awareness and education about cancer screening continue to be significant barriers among populations served by NBCCEDP and CRCCP.
Barrington WE, DeGroff A, Melillo S, Vu T, Cole A, Escoffery C, Askelson N, Seegmiller L, Gonzalez SK, Hannon P. Patient navigator reported patient barriers and delivered activities in two large federally-funded cancer screening programs. Prev Med. 2019 Dec;129S:105858. doi: 10.1016/j.ypmed.2019.105858. Epub 2019 Oct 22. PMID: 31647956; PMCID: PMC7055651.
Specifically, highly reported patient barriers among BCC and CRC PNs included lack of: knowledge about cancer; knowledge about cancer screening procedures; knowledge about the benefit of screening; motivation to get screened; transportation; and health insurance.
Barrington WE, DeGroff A, Melillo S, Vu T, Cole A, Escoffery C, Askelson N, Seegmiller L, Gonzalez SK, Hannon P. Patient navigator reported patient barriers and delivered activities in two large federally-funded cancer screening programs. Prev Med. 2019 Dec;129S:105858. doi: 10.1016/j.ypmed.2019.105858. Epub 2019 Oct 22. PMID: 31647956; PMCID: PMC7055651.
Currently, CDC's patient navigation policy requires that PNs deliver the following six activities: 1) assessment of patient's barriers to cancer screening, diagnostic services, or initiation of cancer treatment; 2) patient education and support; 3) resolution of patient barriers; 4) patient tracking and follow-up over at least two patient contacts to monitor completion of screening and diagnostic testing and treatment initiation; 5) collection of outcomes related to patient navigation (e.g., adherence to screening, diagnostic testing, and treatment); and 6) collection of patient-reported outcomes related to cancer screening, diagnosis, or treatment (Centers for Disease Control and Prevention (CDC); Centers for Disease Control and Prevention (CDC) and Division of Cancer Prevention and Control, 2019)
Barrington WE, DeGroff A, Melillo S, Vu T, Cole A, Escoffery C, Askelson N, Seegmiller L, Gonzalez SK, Hannon P. Patient navigator reported patient barriers and delivered activities in two large federally-funded cancer screening programs. Prev Med. 2019 Dec;129S:105858. doi: 10.1016/j.ypmed.2019.105858. Epub 2019 Oct 22. PMID: 31647956; PMCID: PMC7055651.
Specifically, highly reported navigation activities among BCC and CRC PNs included: talking to patients in clinics about screening; providing one-on-one education; and assessing patient barriers to screening.
Barrington WE, DeGroff A, Melillo S, Vu T, Cole A, Escoffery C, Askelson N, Seegmiller L, Gonzalez SK, Hannon P. Patient navigator reported patient barriers and delivered activities in two large federally-funded cancer screening programs. Prev Med. 2019 Dec;129S:105858. doi: 10.1016/j.ypmed.2019.105858. Epub 2019 Oct 22. PMID: 31647956; PMCID: PMC7055651.
Because there are still disparities in cancer screening, building grantees’ and other community organizations’ capacity to leverage or build partnerships such as those between clinical and community preventive services would promote screening.[[35]]
Escoffery C, Hannon P, Maxwell AE, Vu T, Leeman J, Dwyer A, Mason C, Sowles S, Rice K, Gressard L. Assessment of training and technical assistance needs of Colorectal Cancer Control Program Grantees in the U.S. BMC Public Health. 2015 Jan 31;15:49. doi: 10.1186/s12889-015-1386-1. PMID: 25636329; PMCID: PMC4318175.
Patient navigation (PN) has emerged as an important approach to reduce cancer disparities by addressing barriers to cancer care.
Escoffery C, Fernandez ME, Vernon SW, Liang S, Maxwell AE, Allen JD, Dwyer A, Hannon PA, Kohn M, DeGroff A. Patient Navigation in a Colorectal Cancer Screening Program. J Public Health Manag Pract. 2015 Sep-Oct;21(5):433-40. doi: 10.1097/PHH.0000000000000132. PMID: 25140407; PMCID: PMC4618371.
However, some recent studies with more rigorous study designs have evaluated the effectiveness of PN in increasing CRC screening and found PN effective in addressing individual and system barriers to CRC screening faced by low-income, underserved populations,[[14–16]] improving screening quality, as well as follow-up and diagnostic care, for patients with abnormalities.[[17,18]]
Escoffery C, Fernandez ME, Vernon SW, Liang S, Maxwell AE, Allen JD, Dwyer A, Hannon PA, Kohn M, DeGroff A. Patient Navigation in a Colorectal Cancer Screening Program. J Public Health Manag Pract. 2015 Sep-Oct;21(5):433-40. doi: 10.1097/PHH.0000000000000132. PMID: 25140407; PMCID: PMC4618371.
Continued and improved patient tracking will be essential to supporting screening and rescreening adherence.
Escoffery C, Fernandez ME, Vernon SW, Liang S, Maxwell AE, Allen JD, Dwyer A, Hannon PA, Kohn M, DeGroff A. Patient Navigation in a Colorectal Cancer Screening Program. J Public Health Manag Pract. 2015 Sep-Oct;21(5):433-40. doi: 10.1097/PHH.0000000000000132. PMID: 25140407; PMCID: PMC4618371.
Specific to screening provision, grantees using colonoscopy as the primary test (n = 12) reported that their navigators made reminder calls for colonoscopy appointments and for bowel preparation (both 92%), assisted patients in accessing bowel preparation materials (83%), tracked patients to ensure the procedure was performed (92%), and made follow-up calls after the colonoscopy to check on patients (83%).
Escoffery C, Fernandez ME, Vernon SW, Liang S, Maxwell AE, Allen JD, Dwyer A, Hannon PA, Kohn M, DeGroff A. Patient Navigation in a Colorectal Cancer Screening Program. J Public Health Manag Pract. 2015 Sep-Oct;21(5):433-40. doi: 10.1097/PHH.0000000000000132. PMID: 25140407; PMCID: PMC4618371.
For screening promotion, grantees reported navigators as having made reminder calls for colonoscopy appointments (83%) and assisted patients in accessing bowel preparation materials (83%). Only 56% of grantees reported that navigators made reminder calls to encourage patients to return FOBT or fecal immunochemical test (FIT) tests, although this may reflect fewer programs working with FOBT/FIT testing.
Escoffery C, Fernandez ME, Vernon SW, Liang S, Maxwell AE, Allen JD, Dwyer A, Hannon PA, Kohn M, DeGroff A. Patient Navigation in a Colorectal Cancer Screening Program. J Public Health Manag Pract. 2015 Sep-Oct;21(5):433-40. doi: 10.1097/PHH.0000000000000132. PMID: 25140407; PMCID: PMC4618371.
Also, despite LFC staff providing education about the importance of screening, patients may have had significant competing priorities. Experiencing homelessness posed difficulties in maintaining contact for follow-up. Comorbidities, such as mental health and substance use issues frequently experienced with homelessness (Wadhera et al., 2019), may also be a barrier to completing CRC screening.
Hardin V, Tangka FKL, Wood T, Boisseau B, Hoover S, DeGroff A, Boehm J, Subramanian S. The Effectiveness and Cost to Improve Colorectal Cancer Screening in a Federally Qualified Homeless Clinic in Eastern Kentucky. Health Promot Pract. 2020 Nov;21(6):905-909. doi: 10.1177/1524839920954165. Epub 2020 Sep 29. PMID: 32990049; PMCID: PMC7894067.
According to representatives from LFC, there may be additional barriers facing LFC’s patient population related to transportation and lack of privacy for bowel prep prior to the colonoscopy.
Hardin V, Tangka FKL, Wood T, Boisseau B, Hoover S, DeGroff A, Boehm J, Subramanian S. The Effectiveness and Cost to Improve Colorectal Cancer Screening in a Federally Qualified Homeless Clinic in Eastern Kentucky. Health Promot Pract. 2020 Nov;21(6):905-909. doi: 10.1177/1524839920954165. Epub 2020 Sep 29. PMID: 32990049; PMCID: PMC7894067.
Our assessment of a group of clinics across the nation uncovered positive implementation practices among those implementing mailed fecal testing as well as opportunities for improvement. These opportunities include increasing the proportion of CHCs/FQHCs offering mailed screening; increasing the proportion that provide pre-paid return mail supplies with the screening kit; increasing the proportion of clinics monitoring both screening kit distribution and return; ensuring patients with positive tests can obtain colonoscopy; and increasing sustainability planning and support.
Hohl SD, Maxwell AE, Sharma KP, Sun J, Vu TT, DeGroff A, Escoffery C, Schlueter D, Hannon PA. Implementing Mailed Colorectal Cancer Fecal Screening Tests in Real-World Primary Care Settings: Promising Implementation Practices and Opportunities for Improvement. Prev Sci. 2024 Apr;25(Suppl 1):124-135. doi: 10.1007/s11121-023-01496-3. Epub 2023 Mar 23. PMID: 36952143; PMCID: PMC10034905.
Clinics that used colonoscopy as their primary screening test were significantly less likely to implement mailed fecal testing. Providers’ belief in the effectiveness of FIT may influence their willingness to emphasize its use (Thompson et al., 2019).
Hohl SD, Maxwell AE, Sharma KP, Sun J, Vu TT, DeGroff A, Escoffery C, Schlueter D, Hannon PA. Implementing Mailed Colorectal Cancer Fecal Screening Tests in Real-World Primary Care Settings: Promising Implementation Practices and Opportunities for Improvement. Prev Sci. 2024 Apr;25(Suppl 1):124-135. doi: 10.1007/s11121-023-01496-3. Epub 2023 Mar 23. PMID: 36952143; PMCID: PMC10034905.
Offering mailed fecal testing may be particularly beneficial in rural areas where health care accessibility can be a significant barrier to screening (Davis et al., 2018).
Hohl SD, Maxwell AE, Sharma KP, Sun J, Vu TT, DeGroff A, Escoffery C, Schlueter D, Hannon PA. Implementing Mailed Colorectal Cancer Fecal Screening Tests in Real-World Primary Care Settings: Promising Implementation Practices and Opportunities for Improvement. Prev Sci. 2024 Apr;25(Suppl 1):124-135. doi: 10.1007/s11121-023-01496-3. Epub 2023 Mar 23. PMID: 36952143; PMCID: PMC10034905.
As COVID-19 continues to impede in-person healthcare visits, mailed fecal testing offers an evidence-based alternative to in-person screening tests, and represent an especially promising approach to reduce CRC screening disparities.
Hohl SD, Maxwell AE, Sharma KP, Sun J, Vu TT, DeGroff A, Escoffery C, Schlueter D, Hannon PA. Implementing Mailed Colorectal Cancer Fecal Screening Tests in Real-World Primary Care Settings: Promising Implementation Practices and Opportunities for Improvement. Prev Sci. 2024 Apr;25(Suppl 1):124-135. doi: 10.1007/s11121-023-01496-3. Epub 2023 Mar 23. PMID: 36952143; PMCID: PMC10034905.
The COVID-19 pandemic has caused decreases for breast, cervical, and CRC screening, and mailed fecal testing may offer a means to help maintain screening during public health emergencies (Fisher-Borne et al., 2021) and support screening among those who prefer at-home testing even outside of such emergencies.
Hohl SD, Maxwell AE, Sharma KP, Sun J, Vu TT, DeGroff A, Escoffery C, Schlueter D, Hannon PA. Implementing Mailed Colorectal Cancer Fecal Screening Tests in Real-World Primary Care Settings: Promising Implementation Practices and Opportunities for Improvement. Prev Sci. 2024 Apr;25(Suppl 1):124-135. doi: 10.1007/s11121-023-01496-3. Epub 2023 Mar 23. PMID: 36952143; PMCID: PMC10034905.
As COVID-19 and future pandemics may continue to make in-person healthcare visits more difficult for some time, mailed fecal testing remains an important opportunity to reach populations disproportionately impacted by low CRC screening and poor CRC outcomes (Issaka & Somsouk, 2020; O’Connor et al., 2020).
Hohl SD, Maxwell AE, Sharma KP, Sun J, Vu TT, DeGroff A, Escoffery C, Schlueter D, Hannon PA. Implementing Mailed Colorectal Cancer Fecal Screening Tests in Real-World Primary Care Settings: Promising Implementation Practices and Opportunities for Improvement. Prev Sci. 2024 Apr;25(Suppl 1):124-135. doi: 10.1007/s11121-023-01496-3. Epub 2023 Mar 23. PMID: 36952143; PMCID: PMC10034905.
In this study, based on retrospective self-reports, patients spent, on average, 23.7 h preparing for, traveling for and having a colonoscopy, and an additional 5.1 h, on average, recovering from the colonoscopy. This translated into a total cost of $335.95 for the patient in lost time and $79.03 for the caregiver. In addition, an estimated $17.46 was incurred in travel and other costs. Even when colonoscopy is provided free of charge to the patient, additional costs may be incurred which could be a significant barrier for low income individuals to receive CRC screening.
Hoover S, Subramanian S, Tangka FKL, Cole-Beebe M, Sun A, Kramer CL, Pacillio G. Patients and caregivers costs for colonoscopy-based colorectal cancer screening: Experience of low-income individuals undergoing free colonoscopies. Eval Program Plann. 2017 Jun;62:81-86. doi: 10.1016/j.evalprogplan.2017.01.002. Epub 2017 Jan 7. PMID: 28153341; PMCID: PMC5847315.
Overall, the total cost of undergoing a “free” colonoscopy screening is substantial for a low-income patient, especially when the average hourly wage estimate used in this analysis for the patient was $11.68. This relatively high cost could explain the reason for the lower levels of compliance with screening recommendations among people with low education and generally low socioeconomic status (Centers for Disease Control and Prevention, 2013).
Hoover S, Subramanian S, Tangka FKL, Cole-Beebe M, Sun A, Kramer CL, Pacillio G. Patients and caregivers costs for colonoscopy-based colorectal cancer screening: Experience of low-income individuals undergoing free colonoscopies. Eval Program Plann. 2017 Jun;62:81-86. doi: 10.1016/j.evalprogplan.2017.01.002. Epub 2017 Jan 7. PMID: 28153341; PMCID: PMC5847315.
Financial incentives should be included in future assessments of health promotion interventions, as colonoscopy screening requires a substantial time commitment and the cost of lost time is significant, especially for the low-income population.
Hoover S, Subramanian S, Tangka FKL, Cole-Beebe M, Sun A, Kramer CL, Pacillio G. Patients and caregivers costs for colonoscopy-based colorectal cancer screening: Experience of low-income individuals undergoing free colonoscopies. Eval Program Plann. 2017 Jun;62:81-86. doi: 10.1016/j.evalprogplan.2017.01.002. Epub 2017 Jan 7. PMID: 28153341; PMCID: PMC5847315.
Researchers found that most positive results for FOBTs and FITs were appropriately followed up with colonoscopy to complete the screening process, and most of the colonoscopies were completed within the time frame of 180 days recommended by CDC. Additionally, the authors found that most colonoscopies performed met national quality standards.
Joseph DA, DeGroff A. The CDC Colorectal Cancer Control Program, 2009-2015. Prev Chronic Dis. 2019 Dec 5;16:E159. doi: 10.5888/pcd16.190336. PMID: 31808418; PMCID: PMC6896829.
Collaboration among public health, professional organizations, and other organizations will further develop and strengthen these efforts by continuing to develop and support unified surveillance systems that collect national, population-based data for recommended quality indicators for colonoscopy; provide feedback and the opportunity for quality improvement to endoscopists; provide connections between colonoscopy, pathology, and outcomes data; and support mechanisms to assist endoscopists in monitoring and improving performance.
Joseph DA, DeGroff AS, Hayes NS, Wong FL, Plescia M. The Colorectal Cancer Control Program: partnering to increase population level screening. Gastrointest Endosc. 2011 Mar;73(3):429-34. doi: 10.1016/j.gie.2010.12.027. PMID: 21353839.
Recommended quality indicators include the identification of American Society of Anesthesiology class, cecal intubation rate, documentation of cecal intubation, withdrawal times, documentation of the quality of bowel preparation, adenoma detection rates, documentation of complications, and appropriate surveillance intervals, among others.[[24]]
Joseph DA, DeGroff AS, Hayes NS, Wong FL, Plescia M. The Colorectal Cancer Control Program: partnering to increase population level screening. Gastrointest Endosc. 2011 Mar;73(3):429-34. doi: 10.1016/j.gie.2010.12.027. PMID: 21353839.
The CDC recognizes that, for any screening program to be effective, whether stool-based or endoscopy-based, high-quality colonoscopy must be available.[[23]]
Joseph DA, DeGroff AS, Hayes NS, Wong FL, Plescia M. The Colorectal Cancer Control Program: partnering to increase population level screening. Gastrointest Endosc. 2011 Mar;73(3):429-34. doi: 10.1016/j.gie.2010.12.027. PMID: 21353839.
Because funding for public health programs may be limited or finite, the process of integrating vertical equity is a valuable tool for providing information to target funds where they may be needed most.
Joseph KT, Rice K, Li C. Integrating Equity in a Public Health Funding Strategy. J Public Health Manag Pract. 2016 Jan-Feb;22 Suppl 1(Suppl 1):S68-76. doi: 10.1097/PHH.0000000000000346. PMID: 26599032; PMCID: PMC5737674.
To deliver CRC screening, CRCCP grantees reported more partnerships with primary care clinics, endoscopy/gastrointestinal clinics, and federally qualified health centers than did nongrantees. Both were equally likely to use patient navigators to support screening provision.
Maxwell AE, Hannon PA, Escoffery C, Vu T, Kohn M, Vernon SW, DeGroff A. Promotion and provision of colorectal cancer screening: a comparison of colorectal cancer control program grantees and nongrantees, 2011-2012. Prev Chronic Dis. 2014 Oct 2;11:E170. doi: 10.5888/pcd11.140183. PMID: 25275807; PMCID: PMC4184085.
Common implementation problems include failure to follow up positive stool tests with colonoscopy, wide variation in the ability of endoscopists to detect adenomas, and recommended rescreening or surveillance intervals that do not comply with national guidelines.
Nadel MR, Royalty J, Joseph D, Rockwell T, Helsel W, Kammerer W, Gray SC, Shapiro JA. Variations in Screening Quality in a Federal Colorectal Cancer Screening Program for the Uninsured. Prev Chronic Dis. 2019 May 30;16:E67. doi: 10.5888/pcd16.180452. PMID: 31146803; PMCID: PMC6549419.
Follow-up of positive stool tests with colonoscopy is known to be challenging. A recent systematic review of interventions to improve follow-up found that patient navigators and provider reminders or performance data may help improve follow-up rates.
Nadel MR, Royalty J, Joseph D, Rockwell T, Helsel W, Kammerer W, Gray SC, Shapiro JA. Variations in Screening Quality in a Federal Colorectal Cancer Screening Program for the Uninsured. Prev Chronic Dis. 2019 May 30;16:E67. doi: 10.5888/pcd16.180452. PMID: 31146803; PMCID: PMC6549419.
Sites responded to slow early recruitment by developing more tailored outreach and education, some specifically geared toward men, partnering with existing referral services, expanding partnerships with primary care networks, improving and systematizing the patient enrollment process, and broadening and/or changing the screening test options.[[2,9,11,12]]
Seeff LC, DeGroff A, Joseph DA, Royalty J, Tangka FK, Nadel MR, Plescia M. Moving forward: using the experience of the CDCs' Colorectal Cancer Screening Demonstration Program to guide future colorectal cancer programming efforts. Cancer. 2013 Aug 1;119 Suppl 15:2940-6. doi: 10.1002/cncr.28155. PMID: 23868488.
Partnerships facilitated early through late CRCSDP implementation, aiding start-up through sustainability planning.[[8,13,16,19]] Sites invested time and resources into relationship building that yielded critical clinical partnerships,[[9,16]] a greater reach to priority groups,[[12]] and tangible resources, including those for cancer treatment.[[9,19]]
Seeff LC, DeGroff A, Joseph DA, Royalty J, Tangka FK, Nadel MR, Plescia M. Moving forward: using the experience of the CDCs' Colorectal Cancer Screening Demonstration Program to guide future colorectal cancer programming efforts. Cancer. 2013 Aug 1;119 Suppl 15:2940-6. doi: 10.1002/cncr.28155. PMID: 23868488.
Like the CRCSDP sites, the CRCCP sites partner with health systems, private and public insurers, and FQHCs and encourage the increased use of client and provider reminders at the organizational level to maximize population reach.
Seeff LC, DeGroff A, Joseph DA, Royalty J, Tangka FK, Nadel MR, Plescia M. Moving forward: using the experience of the CDCs' Colorectal Cancer Screening Demonstration Program to guide future colorectal cancer programming efforts. Cancer. 2013 Aug 1;119 Suppl 15:2940-6. doi: 10.1002/cncr.28155. PMID: 23868488.
The well-defined patient pathways, clinical protocols, quality assurance, and tracking systems to guide referral through diagnostic follow-up were critical facilitators in mid- and late implementation.[[13]]
Seeff LC, DeGroff A, Joseph DA, Royalty J, Tangka FK, Nadel MR, Plescia M. Moving forward: using the experience of the CDCs' Colorectal Cancer Screening Demonstration Program to guide future colorectal cancer programming efforts. Cancer. 2013 Aug 1;119 Suppl 15:2940-6. doi: 10.1002/cncr.28155. PMID: 23868488.
Based on analysis of CRCSDP clinical data, the CDC continues to encourage screening programs and clinical communities to conduct routine monitoring of colorectal cancer screening quality indicators as part of an ongoing quality improvement system.
Seeff LC, DeGroff A, Joseph DA, Royalty J, Tangka FK, Nadel MR, Plescia M. Moving forward: using the experience of the CDCs' Colorectal Cancer Screening Demonstration Program to guide future colorectal cancer programming efforts. Cancer. 2013 Aug 1;119 Suppl 15:2940-6. doi: 10.1002/cncr.28155. PMID: 23868488.
The CRCSDP programs that screened with FOBT faced challenges in all these areas, with low card return rates (53%), lower-than-desired rates of follow-up testing for positive FOBT tests (84%), and low rates of rescreening (13%-16%).[[2,3]]
Seeff LC, DeGroff A, Joseph DA, Royalty J, Tangka FK, Nadel MR, Plescia M. Moving forward: using the experience of the CDCs' Colorectal Cancer Screening Demonstration Program to guide future colorectal cancer programming efforts. Cancer. 2013 Aug 1;119 Suppl 15:2940-6. doi: 10.1002/cncr.28155. PMID: 23868488.
Based on the evaluation of this program, we observed challenges associated with both FOBT (substantial loss to follow-up) and colonoscopy (higher program costs translating into fewer people screened).
Seeff LC, DeGroff A, Joseph DA, Royalty J, Tangka FK, Nadel MR, Plescia M. Moving forward: using the experience of the CDCs' Colorectal Cancer Screening Demonstration Program to guide future colorectal cancer programming efforts. Cancer. 2013 Aug 1;119 Suppl 15:2940-6. doi: 10.1002/cncr.28155. PMID: 23868488.
CRCSDP programs encountered problems with patient and provider perceptions that FOBT is an inferior test, limiting its acceptance as a viable alternative to colonoscopy.
Seeff LC, DeGroff A, Joseph DA, Royalty J, Tangka FK, Nadel MR, Plescia M. Moving forward: using the experience of the CDCs' Colorectal Cancer Screening Demonstration Program to guide future colorectal cancer programming efforts. Cancer. 2013 Aug 1;119 Suppl 15:2940-6. doi: 10.1002/cncr.28155. PMID: 23868488.
Our finding that clinics primarily using FIT tests or providing free fecal kits were associated with lower screening rates might represent a relationship between clinics preferring FIT tests and clinics with lower screening rates (such as FQHCs). Additionally, assuring annual FIT testing may be more difficult in contrast to colonoscopy which is required only once each 10 years.
Sharma KP, DeGroff A, Scott L, Shrestha S, Melillo S, Sabatino SA. Correlates of colorectal cancer screening rates in primary care clinics serving low income, medically underserved populations. Prev Med. 2019 Sep;126:105774. doi: 10.1016/j.ypmed.2019.105774. Epub 2019 Jul 15. PMID: 31319118; PMCID: PMC6904949.
Systematic reviews have identified barriers to CRC screening including low levels of education, language or communication issues, low socioeconomic status, lack of insurance coverage, and general attitudes towards prevention (for example, smokers are less likely to seek screening) (Gimeno Garcia, 2012; Subramanian et al., 2004).
Tangka FKL, Subramanian S, Hoover S, Royalty J, Joseph K, DeGroff A, Joseph D, Chattopadhyay S. Costs of promoting cancer screening: Evidence from CDC's Colorectal Cancer Control Program (CRCCP). Eval Program Plann. 2017 Jun;62:67-72. doi: 10.1016/j.evalprogplan.2016.12.008. Epub 2016 Dec 12. PMID: 27989647; PMCID: PMC5840873.
The patient navigator identified barriers (N=148) to patients being screened for colorectal cancer or other cancers. The largest categories of barriers identified included financial or insurance issues (30.4%, 45/148); psychosocial issues, such as fear of the test and fear of test outcome (23.6%; 35/148); and transportation (23.6%; 35/148).
Tangka FKL, Subramanian S, Hoover S, Cariou C, Creighton B, Hobbs L, Marzano A, Marcotte A, Norton DD, Kelly-Flis P, Leypoldt M, Larkins T, Poole M, Boehm J. Improving the efficiency of integrated cancer screening delivery across multiple cancers: case studies from Idaho, Rhode Island, and Nebraska. Implement Sci Commun. 2022 Dec 16;3(1):133. doi: 10.1186/s43058-022-00381-4. PMID: 36527147; PMCID: PMC9756516.
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