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A New Paradigm for Increasing Use of Open-Access Screening Colonoscopy
A New Paradigm for Increasing Use of Open-Access Screening Colonoscopy
C
olorectal cancer (CRC) remains a leading cause of cancer incidence and mortality in the United States.1 CRC takes a particularly high toll on African Americans, who suffer a disproportionate burden of disease relative to whites. Unlike other cancers, however, screening has been shown to be not only a cost-effective strategy for reducing mortality through early detection, but also for reducing incidence through the identification and removal of precancerous adenomatous polyps. Moreover, sufficient evidence has accumulated to warrant widespread endorsement by most authoritative groups, including the American Cancer Society, the US Preventive Services Task Force, and the US Multisociety Task Force on Colorectal Cancer. Virtually all such groups recommend a menu of screening options for average-risk individuals that includes annual fecal occult blood testing with or without flexible sigmoidoscopy every 5 years, flexible sigmoidoscopy alone every 5 years, double-contrast barium enema every 5 years, or colonoscopy every 10 years. This option-based approach is predicated largely on the results of economic analyses, which find that the incremental cost effectiveness of each of these strategies is comparable (⬍$25,000 per life-year saved) and superior to no screening.2 Despite the lack of consensus regarding an optimal strategy in terms of cost effectiveness, colonoscopy has emerged as the preferred screening option by both providers and patients.3,4 This surge in demand is attributable to several factors, including superior accuracy for detecting both cancers and advanced adenomas, more widespread coverage by medical insurers, potential liability concerns, heightened promotion in most public awareness campaigns, and, most notably, endorsement by highly visible celebrities such as the former Today Show host Katie Couric. Colonoscopy also is attractive because it has the advantage of being both a diagnostic and therapeutic modality and only needs to be performed every 10 years if normal. Even with the good news that screening by any of the recommended methods can reduce CRC incidence and mortality, participation remains low and lags behind breast and prostate cancer. Population-based surveys found that although these rates have increased steadily in recent years, largely owing to increased use of colonoscopy, nearly half of all eligible Americans are in need of screening.3,5 These surveys also consistently found sociodemographic disparities in the use of screening tests, with lower rates among women, minorities, and the uninsured. Regardless of the screening test, the lack of a provider recommendation is widely recognized as one of the main barriers to CRC screening.6 Many unscreened patients report that their providers either never recommended screening or were told that it was not necessary in the absence of symptoms (Holt et al, unpublished data). Apart from the lack of a provider recommendation, numerous patient- and health systems–related barriers to screening also have been identified. Although extensive literature exists regarding barriers to CRC screening in general, several recent
studies have focused on identifying predictors of nonadherence to screening colonoscopy.7,8 Commonly cited patient-related barriers to colonoscopy completion include cognitive-emotional factors (eg, lack of awareness about the importance of screening, lack of perceived risk, fear of pain, embarrassment, and concerns about the bowel preparation) and logistical obstacles (eg, costs, other health issues, competing demands on time related to work or family responsibilities, and need for transportation). Commonly cited health systems–related barriers include lack of reminder and tracker systems, lack of universal coverage, scheduling challenges, and long waiting times. The use of an open-access referral system has been advocated as a potentially effective strategy for increasing adherence to screening colonoscopy. Proponents argue that this approach both reduces some of the logistical constraints related to screening by obviating the need for a preprocedure office visit and increases access by enabling endoscopists to spend more time in the endoscopy unit and less time in the clinic. Nevertheless, open-access systems present unique challenges with regards to scheduling, minimizing medicolegal risks, and communicating with patients and referring providers before and after the procedure. Hitherto, few studies have examined the extent to which the open-access systems are successful in optimizing the use of screening colonoscopy in the community setting. In this issue of Clinical Gastroenterology and Hepatology, Kazarian et al9 report on colonoscopy completion rates in a large safety net health care system. Based on their anecdotal experience, the investigators postulated that test completion rates among poor and minority patients referred through an openaccess system would be low because of high nonattendance rates and high rates of inadequate bowel preparation leading to incomplete and aborted examinations. To test this hypothesis, they conducted a 6-month retrospective review of patients referred for outpatient screening and diagnostic colonoscopy using an open-access referral system to determine rates and sociodemographic predictors of colonoscopy nonattendance and inadequate (fair/poor) bowel preparation. As expected, the authors observed a 41.7% nonattendance rate and a 30.2% inadequate bowel preparation rate, with 9.9% of bowel preparations precluding complete examination. Although markedly higher rates of nonattendance and inadequate bowel preparation were observed among correctional care patients, no significant associations were observed for age, sex, race, payer, or indication. This study is important for several reasons. First, it validates a widespread belief that open-access endoscopy has serious deficiencies as a strategy for facilitating the use of screening colonoscopy in the community setting. Second, because all referrals were generated by the primary care providers within the safety net health care system, it clearly shows that a provider recommendation alone is insufficient for ensuring patient participation. Second, because the vast majority of patients had coverage with minimal or no co-pay, it also suggests that minimizing out-of-pocket costs alone also is unlikely to increase adherence among this patient population. Perhaps most importantly, it highlights the need for interventions at multiple levels to ensure that patients are educated properly about the imporCLINICAL GASTROENTEROLOGY AND HEPATOLOGY 2008;6:377-378
378
EDITORIALS
tance of the bowel preparation, that an effective reminder system exists to ensure that patients are well aware of the date/time of the examination, and a that a mechanism exists for addressing potential psychosocial and cultural barriers (eg, mistrust, fear, and perceived discrimination) that compromise adherence to screening. The use of patient navigators is one such intervention that could assist patients at multiple levels and potentially increase test completion rates among underserved patient populations. Patient navigators are individuals trained to guide patients through the health care system to receive appropriate services. Although patient navigation initially was developed to ensure that patients with abnormal screening test results received appropriate follow-up evaluation, more recent studies have suggested a role in the delivery of preventive services. The study by Chen et al,10 which also appears in this issue of Clinical Gastroenterology and Hepatology, reports on the utility of patient navigation for increasing screening colonoscopy completion rates within an open-access referral system serving urban minorities. To address the problem of high no-show rates, a program was initiated in which primary care referrals for screening colonoscopy were forwarded to a trained, bilingual, female health educator (patient navigator), who assumed responsibility for scheduling, patient education, sending out bowel preparation instructions, conducting reminder phone calls, arranging transportation if necessary, and addressing potential barriers. By using this approach, the investigators found that 66% of navigated patients completed screening colonoscopies and only 5% had inadequate bowel preparations. Importantly, they also found that the no-show rate decreased from 40% before initiation of the program to 9.8%, and that Hispanics, particularly Hispanic women, were significantly more likely to complete their examinations than African Americans. Moreover, patient satisfaction was high, with 66% of patients reporting that they definitely or probably would not have completed their colonoscopy without navigation. Although these results are impressive, the study had several important limitations. First, important questions remain regarding the generalizability of the findings to other clinical settings with more diverse patient populations and unique barriers to screening (eg, multiple languages, lack of insurance, unreliable contact information, and so forth). Even in this study, only 75% of subjects were deemed eligible for navigation. Second, important questions remain regarding the appropriate demographic profile, qualifications, and training necessary for success as a patient navigator. Third, because no cost data were provided, the cost effectiveness of patient navigation needs to be defined. Although the revenues generated from increased productivity related to higher attendance rates and completed examinations may offset personnel costs, plans for distribution of such funds are needed if patient navigators are better suited for use in primary care settings. Finally, future study is needed to gain insight into reasons why nearly one third of navigated patients failed to complete their colonoscopy. In conclusion, open-access referral systems for screening colonoscopy are subject to high no-show rates and inadequate bowel preparation, which not only compromise the overall effectiveness of CRC screening but also the productivity of the
CLINICAL GASTROENTEROLOGY AND HEPATOLOGY Vol. 6, No. 4
endoscopy unit, which in turn contributes to the capacity constraints confronting population-based screening. The patient navigator approach appears to be an effective way to increase completion rates, but there are many important unanswered questions regarding optimizing use in diverse clinical settings. In the interim, eliciting patient preferences within the framework of shared decision making may be an effective strategy for identifying patients more or less likely to complete their examination and, in so doing, make better use of existing resources. We clearly have a long way to go, but the future looks promising.
CHERYL L. HOLT, PHD Department of Medicine Division of Preventive Medicine The University of Alabama at Birmingham Birmingham, AL PAUL C. SCHROY III, MD, MPH Department of Medicine Boston University School of Medicine Section of Gastroenterology Boston Medical Center Boston, MA References 1. Jemal A, Siegel R, Ward E, et al. Cancer statistics, 2007. CA Cancer J Clin 2007;57:43– 66. 2. Pignone M, Saha S, Hoerger T, et al. Cost-effectiveness analyses of colorectal cancer screening: a systematic review for the U.S. Preventive Services Task Force. Ann Intern Med 2002;137:96 – 104. 3. Meissner HI, Breen N, Klabunde CN, et al. Patterns of colorectal cancer screening uptake among men and women in the United States. Cancer Epidemiol Biomarkers Prev 2006;15:389 –394. 4. Schroy PC 3rd, Lal S, Glick JT, et al. Patient preferences for colorectal cancer screening: how does stool DNA testing fare? Am J Manag Care 2007;13:393– 400. 5. Centers for Disease Control and Prevention. Increased use of colorectal cancer screening tests—United States, 2002 and 2004. MMWR Morb Mortal Wkly Rep 2006;55:308 –311. 6. Seeff LC, Nadel MR, Klabunde CN, et al. Patterns and predictors of colorectal cancer test use in the adult U.S. population. Cancer 2004;100:2093–2103. 7. Denberg TD, Melhado TV, Coombes JM, et al. Predictors of nonadherence to screening colonoscopy. J Gen Intern Med 2005;20: 989 –995. 8. Harewood GC, Wiersema MJ, Melton LJ 3rd. A prospective, controlled assessment of factors influencing acceptance of screening colonoscopy. Am J Gastroenterol 2002;97:3186 –3194. 9. Kazarian E, Carreira F, Toribara NW, et al. Colonoscopy completion in a large safety net health care system. Clin Gastroenterol Hepatol 2008;6:438 – 442. 10. Chen LA, Santos S, Jandorf L, et al. A program to enhance completion of screening colonoscopy among minority populations. Clin Gastroenterol Hepatol 2008;6:443– 450.
doi:10.1016/j.cgh.2008.02.015
C
olorectal cancer (CRC) remains a leading cause of cancer incidence and mortality in the United States.1 CRC takes a particularly high toll on African Americans, who suffer a disproportionate burden of disease relative to whites. Unlike other cancers, however, screening has been shown to be not only a cost-effective strategy for reducing mortality through early detection, but also for reducing incidence through the identification and removal of precancerous adenomatous polyps. Moreover, sufficient evidence has accumulated to warrant widespread endorsement by most authoritative groups, including the American Cancer Society, the US Preventive Services Task Force, and the US Multisociety Task Force on Colorectal Cancer. Virtually all such groups recommend a menu of screening options for average-risk individuals that includes annual fecal occult blood testing with or without flexible sigmoidoscopy every 5 years, flexible sigmoidoscopy alone every 5 years, double-contrast barium enema every 5 years, or colonoscopy every 10 years. This option-based approach is predicated largely on the results of economic analyses, which find that the incremental cost effectiveness of each of these strategies is comparable (⬍$25,000 per life-year saved) and superior to no screening.2 Despite the lack of consensus regarding an optimal strategy in terms of cost effectiveness, colonoscopy has emerged as the preferred screening option by both providers and patients.3,4 This surge in demand is attributable to several factors, including superior accuracy for detecting both cancers and advanced adenomas, more widespread coverage by medical insurers, potential liability concerns, heightened promotion in most public awareness campaigns, and, most notably, endorsement by highly visible celebrities such as the former Today Show host Katie Couric. Colonoscopy also is attractive because it has the advantage of being both a diagnostic and therapeutic modality and only needs to be performed every 10 years if normal. Even with the good news that screening by any of the recommended methods can reduce CRC incidence and mortality, participation remains low and lags behind breast and prostate cancer. Population-based surveys found that although these rates have increased steadily in recent years, largely owing to increased use of colonoscopy, nearly half of all eligible Americans are in need of screening.3,5 These surveys also consistently found sociodemographic disparities in the use of screening tests, with lower rates among women, minorities, and the uninsured. Regardless of the screening test, the lack of a provider recommendation is widely recognized as one of the main barriers to CRC screening.6 Many unscreened patients report that their providers either never recommended screening or were told that it was not necessary in the absence of symptoms (Holt et al, unpublished data). Apart from the lack of a provider recommendation, numerous patient- and health systems–related barriers to screening also have been identified. Although extensive literature exists regarding barriers to CRC screening in general, several recent
studies have focused on identifying predictors of nonadherence to screening colonoscopy.7,8 Commonly cited patient-related barriers to colonoscopy completion include cognitive-emotional factors (eg, lack of awareness about the importance of screening, lack of perceived risk, fear of pain, embarrassment, and concerns about the bowel preparation) and logistical obstacles (eg, costs, other health issues, competing demands on time related to work or family responsibilities, and need for transportation). Commonly cited health systems–related barriers include lack of reminder and tracker systems, lack of universal coverage, scheduling challenges, and long waiting times. The use of an open-access referral system has been advocated as a potentially effective strategy for increasing adherence to screening colonoscopy. Proponents argue that this approach both reduces some of the logistical constraints related to screening by obviating the need for a preprocedure office visit and increases access by enabling endoscopists to spend more time in the endoscopy unit and less time in the clinic. Nevertheless, open-access systems present unique challenges with regards to scheduling, minimizing medicolegal risks, and communicating with patients and referring providers before and after the procedure. Hitherto, few studies have examined the extent to which the open-access systems are successful in optimizing the use of screening colonoscopy in the community setting. In this issue of Clinical Gastroenterology and Hepatology, Kazarian et al9 report on colonoscopy completion rates in a large safety net health care system. Based on their anecdotal experience, the investigators postulated that test completion rates among poor and minority patients referred through an openaccess system would be low because of high nonattendance rates and high rates of inadequate bowel preparation leading to incomplete and aborted examinations. To test this hypothesis, they conducted a 6-month retrospective review of patients referred for outpatient screening and diagnostic colonoscopy using an open-access referral system to determine rates and sociodemographic predictors of colonoscopy nonattendance and inadequate (fair/poor) bowel preparation. As expected, the authors observed a 41.7% nonattendance rate and a 30.2% inadequate bowel preparation rate, with 9.9% of bowel preparations precluding complete examination. Although markedly higher rates of nonattendance and inadequate bowel preparation were observed among correctional care patients, no significant associations were observed for age, sex, race, payer, or indication. This study is important for several reasons. First, it validates a widespread belief that open-access endoscopy has serious deficiencies as a strategy for facilitating the use of screening colonoscopy in the community setting. Second, because all referrals were generated by the primary care providers within the safety net health care system, it clearly shows that a provider recommendation alone is insufficient for ensuring patient participation. Second, because the vast majority of patients had coverage with minimal or no co-pay, it also suggests that minimizing out-of-pocket costs alone also is unlikely to increase adherence among this patient population. Perhaps most importantly, it highlights the need for interventions at multiple levels to ensure that patients are educated properly about the imporCLINICAL GASTROENTEROLOGY AND HEPATOLOGY 2008;6:377-378
378
EDITORIALS
tance of the bowel preparation, that an effective reminder system exists to ensure that patients are well aware of the date/time of the examination, and a that a mechanism exists for addressing potential psychosocial and cultural barriers (eg, mistrust, fear, and perceived discrimination) that compromise adherence to screening. The use of patient navigators is one such intervention that could assist patients at multiple levels and potentially increase test completion rates among underserved patient populations. Patient navigators are individuals trained to guide patients through the health care system to receive appropriate services. Although patient navigation initially was developed to ensure that patients with abnormal screening test results received appropriate follow-up evaluation, more recent studies have suggested a role in the delivery of preventive services. The study by Chen et al,10 which also appears in this issue of Clinical Gastroenterology and Hepatology, reports on the utility of patient navigation for increasing screening colonoscopy completion rates within an open-access referral system serving urban minorities. To address the problem of high no-show rates, a program was initiated in which primary care referrals for screening colonoscopy were forwarded to a trained, bilingual, female health educator (patient navigator), who assumed responsibility for scheduling, patient education, sending out bowel preparation instructions, conducting reminder phone calls, arranging transportation if necessary, and addressing potential barriers. By using this approach, the investigators found that 66% of navigated patients completed screening colonoscopies and only 5% had inadequate bowel preparations. Importantly, they also found that the no-show rate decreased from 40% before initiation of the program to 9.8%, and that Hispanics, particularly Hispanic women, were significantly more likely to complete their examinations than African Americans. Moreover, patient satisfaction was high, with 66% of patients reporting that they definitely or probably would not have completed their colonoscopy without navigation. Although these results are impressive, the study had several important limitations. First, important questions remain regarding the generalizability of the findings to other clinical settings with more diverse patient populations and unique barriers to screening (eg, multiple languages, lack of insurance, unreliable contact information, and so forth). Even in this study, only 75% of subjects were deemed eligible for navigation. Second, important questions remain regarding the appropriate demographic profile, qualifications, and training necessary for success as a patient navigator. Third, because no cost data were provided, the cost effectiveness of patient navigation needs to be defined. Although the revenues generated from increased productivity related to higher attendance rates and completed examinations may offset personnel costs, plans for distribution of such funds are needed if patient navigators are better suited for use in primary care settings. Finally, future study is needed to gain insight into reasons why nearly one third of navigated patients failed to complete their colonoscopy. In conclusion, open-access referral systems for screening colonoscopy are subject to high no-show rates and inadequate bowel preparation, which not only compromise the overall effectiveness of CRC screening but also the productivity of the
CLINICAL GASTROENTEROLOGY AND HEPATOLOGY Vol. 6, No. 4
endoscopy unit, which in turn contributes to the capacity constraints confronting population-based screening. The patient navigator approach appears to be an effective way to increase completion rates, but there are many important unanswered questions regarding optimizing use in diverse clinical settings. In the interim, eliciting patient preferences within the framework of shared decision making may be an effective strategy for identifying patients more or less likely to complete their examination and, in so doing, make better use of existing resources. We clearly have a long way to go, but the future looks promising.
CHERYL L. HOLT, PHD Department of Medicine Division of Preventive Medicine The University of Alabama at Birmingham Birmingham, AL PAUL C. SCHROY III, MD, MPH Department of Medicine Boston University School of Medicine Section of Gastroenterology Boston Medical Center Boston, MA References 1. Jemal A, Siegel R, Ward E, et al. Cancer statistics, 2007. CA Cancer J Clin 2007;57:43– 66. 2. Pignone M, Saha S, Hoerger T, et al. Cost-effectiveness analyses of colorectal cancer screening: a systematic review for the U.S. Preventive Services Task Force. Ann Intern Med 2002;137:96 – 104. 3. Meissner HI, Breen N, Klabunde CN, et al. Patterns of colorectal cancer screening uptake among men and women in the United States. Cancer Epidemiol Biomarkers Prev 2006;15:389 –394. 4. Schroy PC 3rd, Lal S, Glick JT, et al. Patient preferences for colorectal cancer screening: how does stool DNA testing fare? Am J Manag Care 2007;13:393– 400. 5. Centers for Disease Control and Prevention. Increased use of colorectal cancer screening tests—United States, 2002 and 2004. MMWR Morb Mortal Wkly Rep 2006;55:308 –311. 6. Seeff LC, Nadel MR, Klabunde CN, et al. Patterns and predictors of colorectal cancer test use in the adult U.S. population. Cancer 2004;100:2093–2103. 7. Denberg TD, Melhado TV, Coombes JM, et al. Predictors of nonadherence to screening colonoscopy. J Gen Intern Med 2005;20: 989 –995. 8. Harewood GC, Wiersema MJ, Melton LJ 3rd. A prospective, controlled assessment of factors influencing acceptance of screening colonoscopy. Am J Gastroenterol 2002;97:3186 –3194. 9. Kazarian E, Carreira F, Toribara NW, et al. Colonoscopy completion in a large safety net health care system. Clin Gastroenterol Hepatol 2008;6:438 – 442. 10. Chen LA, Santos S, Jandorf L, et al. A program to enhance completion of screening colonoscopy among minority populations. Clin Gastroenterol Hepatol 2008;6:443– 450.
doi:10.1016/j.cgh.2008.02.015