番茄社区

Certain barriers to colonoscopy completion among patients with abnormal fecal immunochemical test (FIT) results may be modifiable, a survey of healthcare workers at a safety net health system suggested.

In a qualitative study involving primary care physicians and staff, frequently cited obstacles to colonoscopy completion after an abnormal FIT included social determinants of health, organizational factors, and patient cognition, reported Rachel Issaka, MD, of the Fred Hutchinson Cancer Research Center in Seattle, and colleagues.

For social determinants of health, patients' lack of transportation was most often mentioned (57%), followed by language barriers (52%) and homelessness (38%), according to the findings in .

Organizational issues standing in the way of colonoscopy completion included a lack of coordinated care (28%), as well as staffing- (19%) and pandemic-related issues (9%). Patient cognitive factors included the challenges associated with bowel preparation (61%) such as restroom access, health literacy issues (47%), and fear of a cancer diagnosis (42%).

The study involved a survey of 10 primary care physicians and 11 healthcare staff members at Harborview Medical Center (HMC), a safety net healthcare system in the Seattle region affiliated with the University of Washington. Recent data from the system showed that only 41% of people with an abnormal FIT from 2014 to 2018 completed their colonoscopy.

Colorectal cancer is prevalent in an estimated 3.4% of patients with abnormal FIT results, and a missed or even delayed colonoscopy is associated with increased cancer mortality, the authors noted. The U.S. Multi-Society Task Force has a follow-up colonoscopy goal of 80%.

"Incorporating clinician-identified factors into multilevel interventions may be associated with improved colonoscopy completion among patients with abnormal FIT results and help address one of the most persistent challenges in cancer prevention and control for safety net and other medically underserved populations," Issaka's group concluded.

Interventions commonly cited in the survey for addressing these barriers included interpretation assistance (47%), scheduling in-person follow-up appointments (47%), insurance assistance (28%), transportation assistance (23%), as well as general patient education (33%) and education specific to bowel preparation (9%).

A number of things need to happen for colonoscopy completion among vulnerable patients, Neil Hyman, MD, of the University of Chicago, told 番茄社区.

"First, a person needs to know how to get a ride to the outpatient center. Second, they need someone to take them home," said Hyman, who was not involved in the research. "Third, they need access to pharmacies and access to bowel preparation."

One physician interviewed for the study proposed rideshares, but Issaka's group noted that "rideshare interventions have not yet been explored for colonoscopy completion due to associated procedural sedation."

Lack of telephone access was also cited as a barrier in the study.

"It is hard sometimes to get patients to answer the phone," said Hyman. He added that "hospital processes can be extremely complex" and that safety net hospitals in particular can be more difficult to navigate than outpatient clinics.

"This article shows us just how important these barriers to health and to colonoscopy completion really are -- we need to be creative in how to address these disparities," said Adjoa Anyane-Yeboa, MD, MPH, of Harvard Medical School in Boston, who also was not involved in the study. "Hospitals and healthcare systems need to put financial resources aside for patient navigation and preparation."

Anyane-Yeboa told 番茄社区 that the amnestic effects of colonoscopies, which can last hours or even up to the rest of the day, creates a "loophole" in the possible rideshare solution for transportation barriers.

For their study, the researchers interviewed 21 HMC physicians and staff from February to December 2020. Participants had to be primary care clinic employees and provide care for patients over age 50 with abnormal FIT results. Roughly half of the staff spent 75% or more of their days in direct patient care.

The semi-structured interview guide was driven by the , a consistent public health framework. Participants were paid $100 for the interviews. Median age of respondents was 38 years and about 85% were women. Roughly 10% were Black, about one-third were white, half were Asian, and 5% were Hispanic.

Study limitations included the small number of participants, that it was restricted to an urban safety net teaching hospital, and the lack of patient interviews to further identify barriers.

Comment