Which factors affect completion of routine colonoscopies and what is their impact?
The implementation of patient navigation (PN) services can be used to support multiple functions related to increasing completion of routine colonoscopies. In this context, providing patients with PN services can help ensure adequate bowel prep is done ahead of routine colonoscopies and that patients arrive on time for their appointment.[[99, 101]] PN also helps increase and individualize patient education and outreach about, for example, the importance of CRC screening.[[41, 42, 99, 101]] Tailored patient education and outreach then, in turn, helps reduce patient barriers to screening[[87, 88, 274]] that include the cost of screening due to time lost use,[[163-165]] insurance barriers,[[456]] language barriers,[[427]] educational barriers,[[38, 39, 427]] lacking privacy for bowel prep,[[137]] and competing priorities such as mental health challenges or substance use.[[136]] Reducing barriers to screening increases the number of colonoscopies successfully completed.
PN services can also facilitate and strengthen partnerships between clinics and endoscopy partners, as well as partnerships between clinics and community organizations, by serving as a bridge between organizations. For example, the more patients who have adequate bowel prep and arrive on time for their colonoscopies (e.g., reducing no-shows) strengthens the quality of partnerships between clinics and endoscopy providers because more colonoscopies are successfully completed. Increased partnerships between clinics and community organizations increases the extent to which patient education and outreach is available to support CRC screening.[[79, 275]] The higher the number and the quality of partnerships between clinics and endoscopy providers, the more colonoscopies completed.[[226]]
There is a small balancing loop between the number of patients due for CRC screening and the number of colonoscopies completed, meaning that increases in completed colonoscopies improve overall CRC screening, but once CRC screening prevalence is high, the number of colonoscopies to be completed will decrease (i.e., less demand for colonoscopies as more people are up-to-date on CRC screening). Finally, another factor to consider is the importance of providing colonoscopies that meet quality metrics established by professional organizations for gastroenterology.[[182, 184-186, 235, 239, 241, 280]] The more colonoscopies completed, the more that meet the quality metrics, which increases the number of CRC cases detected. Standardizing endoscopic practices, offering quality training to providers, and implementing provider assessment and feedback increases the number of colonoscopies completed that meet quality standards.[[184]]
Cited references for this diagram
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.
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.
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.
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.
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.
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.
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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