FIT indicates fecal immunochemical test.
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Issaka RB, Bell-Brown A, Snyder C, et al. Perceptions on Barriers and Facilitators to Colonoscopy Completion After Abnormal Fecal Immunochemical Test Results in a Safety Net System. JAMA Netw Open. 2021;4(8):e2120159. doi:10.1001/jamanetworkopen.2021.20159
What are the clinician-identified barriers and facilitators to colonoscopy completion among patients with abnormal fecal immunochemical test (FIT) results in a safety net health care system?
In this qualitative study of 21 primary care physicians (PCPs) and staff members, barriers to follow-up colonoscopy completion included environmental factors (ie, social determinants of health and organizational factors) and patient cognitive factors. Resources that addressed these barriers (eg, insurance assistance, appointment reminders, and bowel preparation education) were associated with improved colonoscopy completion.
These findings suggest that interventions to improve colonoscopy completion among patients with abnormal FIT results should be informed by clinician-identified barriers and facilitators.
The effectiveness of stool-based colorectal cancer (CRC) screening, including fecal immunochemical tests (FITs), relies on colonoscopy completion among patients with abnormal results, but in safety net systems and federally qualified health centers, in which FIT is frequently used, colonoscopy completion within 1 year of an abnormal result rarely exceeds 50%. Clinician-identified factors in follow-up of abnormal FIT results are understudied and could lead to more effective interventions to address this issue.
To describe clinician-identified barriers and facilitators to colonoscopy completion among patients with abnormal FIT results in a safety net health care system.
Design, Setting, and Participants
This qualitative study was conducted using semistructured key informant interviews with primary care physicians (PCPs) and staff members in a large safety net health care system in Washington state. Eligible clinicians were recruited through all-staff meetings and clinic medical directors. Interviews were conducted from February to December 2020 through face-to-face interactions or digital meeting platforms. Interview transcripts were analyzed deductively and inductively using a content analysis approach. Data were analyzed from September through December 2020.
Main Outcomes and Measures
Barriers and facilitators to colonoscopy completion after an abnormal FIT result were identified by PCPs and staff members.
Among 21 participants, there were 10 PCPs and 11 staff members; 20 participants provided demographic information. The median (interquartile range) age was 38.5 (33.0-51.5) years, 17 (85.0%) were women, and 9 participants (45.0%) spent more than 75% of their working time engaging in patient care. All participants identified social determinants of health, organizational factors, and patient cognitive factors as barriers to colonoscopy completion. Participants suggested that existing resources that addressed these factors facilitated colonoscopy completion but were insufficient to meet national follow-up colonoscopy goals.
Conclusions and Relevance
In this qualitative study, responses of interviewed PCPs and staff members suggested that the barriers to colonoscopy completion in a safety net health system may be modifiable. These findings suggest that interventions to improve follow-up of abnormal FIT results should be informed by clinician-identified factors to address multilevel challenges to colonoscopy completion.
There is clear evidence that screening for colorectal cancer (CRC) by stool-based tests is cost-effective1 and saves lives2; however, screening remains underused, especially among members of racial/ethnic minority groups and low-income populations.3 In safety net health care settings and federally qualified health centers (FQHCs) (eTable in the Supplement), in which many medically underserved populations receive care, CRC screening improves when a fecal immunochemical test (FIT) is offered alongside colonoscopy.4 Additionally, owing to patient preference and limited resources,5 FIT has become a cornerstone for CRC screening in these settings. Among patients with an abnormal FIT result, the estimated CRC prevalence is 3.4%6 and a missed or delayed diagnostic colonoscopy is associated with increased CRC mortality.7,8 Despite these concerns, the proportion of patients with an abnormal FIT result who complete a diagnostic colonoscopy rarely exceeds 50% in most safety net systems and FQHCs.9-11
At Harborview Medical Center (HMC), a safety net health care system for the Seattle region, among 299 adults ages 50 to 75 with an abnormal FIT result for CRC screening from 2014 to 2018, 122 individuals (40.8%), completed a colonoscopy within 1 year of their abnormal result (patient electronic health record [EHR] data obtained by R.B.I. from University of Washington Medicine Information Technology Services on November 20, 2019). Our prior work10 examining colonoscopy completion in a different safety net health care system similarly found inadequate colonoscopy completion rates. Colonoscopy completion is a complex process that requires effective communication and coordination among patients, primary and specialty care clinicians, and the health care system.12 In 2 studies from 2021, 31%13 and 46%14 of patients completed a colonoscopy within 6 months of their abnormal FIT results after receiving patient navigation. While these results are promising, they suggest the need for additional interventions to achieve the US Multi-Society Task Force (USMSTF) follow-up colonoscopy goal of 80%.
Improving follow-up colonoscopy completion is a priority for HMC leaders and administrators, but evidence-based guidance on where to intervene along the screening continuum is needed. A 2017 review15 of interventions to improve colonoscopy completion after abnormal stool-based CRC screening test results lacked representation from FQHCs or safety net health systems. A 2018 meta-analysis16 could not determine the overall effectiveness of any intervention because of the low number of available studies. Qualitative studies could fill an important knowledge gap and aid in the development of interventions to reach the 80% follow-up goal. There is also a need for studies that include safety net health systems and FQHCs. In these settings, understanding clinician-specific factors associated with colonoscopy completion may lead to more effective interventions to address this persistent issue. The aim of this study is to describe clinician-identified barriers and facilitators to colonoscopy completion among patients with abnormal FIT results. Our goal is to inform interventions aimed at improving follow-up of abnormal FIT results and CRC outcomes in FQHCs and safety net systems.
In this qualitative study, we conducted semistructured, key informant interviews of primary care physicians (PCPs) and staff members within HMC from February to December 2020. This study adhered to the Consolidated Criteria for Reporting Qualitative Research (COREQ) reporting guideline17 and was approved by the Fred Hutch/University of Washington Cancer Consortium’s institutional review board. All participants provided verbal consent to be recorded and to have their data and responses published. Each participant received a $100 cash incentive for their time.
HMC is a safety net county teaching hospital system in Seattle, Washington, with 7 primary care clinics that provide care to historically underserved populations in King County, including individuals of lower socioeconomic status, who are uninsured, and whose primary language is not English. All HMC clinics, through their affiliation with the University of Washington, share a single integrated EHR.
Clinic medical directors identified HMC PCPs and staff members involved in follow-up of abnormal FIT results. We then recruited a convenience sample of participants from the 7 HMC primary care clinics through all-staff meetings. Study staff contacted interested individuals by email for further eligibility assessment and enrollment. Participants were eligible if they were employed by an HMC primary care clinic that provided care to adults aged 18 years and older and personally provided care to adults aged 50 years or older who used FIT for CRC screening. Participants included PCPs (ie, attending physicians and residents) and staff members (ie, physician assistants, nurses, patient care coordinators, medical assistants, clinic managers, and caseworkers). By directing the delivery of medical care and assisting patients in accessing health care services, patient care coordinators are often a point of contact among clinicians, patients, and family members.
The goal of our interviews was to identify potentially modifiable barriers and facilitators that cannot be gleaned from EHR but that if addressed may be associated with improved follow-up colonoscopy completion. The semistructured interview guide was developed through several iterations with the study team and was informed by social cognitive theory (Figure),18 which we selected for 3 reasons: (1) it is consistent with the social-ecological perspective that the health and behavior of individuals are determined by factors at multiple levels ranging from the intrapersonal to the societal; (2) it is a widely used theoretical framework in public health because it gives explicit guidance about methods for intervention development that promote health-enhancing behavioral change;19 and (3) it has been successfully applied to develop interventions to address a wide variety of health conditions and behaviors.20 The interviews took a mean of 30 to 40 minutes to complete.
Interviews were conducted and recorded by 3 authors (R.B.I., A.B.B., and D.A.) in person or via a secure conferencing platform from February to December 2020. All participants were assigned participant numbers and deidentified to the remaining research team. Interviews were transcribed verbatim, verified against recordings, and uploaded to data management software by participant number. Following accepted standards of rigor in qualitative research, we collected data until thematic saturation was achieved.21 To ensure our findings were relevant to diverse health care settings and clinicians, participants were asked to self-identify their race and ethnicity in an accompanying demographics survey.
Participant demographic data were described as proportions or medians and interquartile ranges (IQRs). For our qualitative analysis, we applied directed content analysis to all data.22 First, in a deductive approach, 3 authors (R.B.I., A.B.B., and C.S.), developed an initial list of codes and definitions that corresponded with research goals (eg, perceived barriers and facilitators to colonoscopy completion) and constructs of social cognitive theory (eg, social, organizational, and cognitive factors). Code labels and definitions were discussed to ensure accuracy. Next, in an inductive approach, coders independently reviewed a subset of the same interviews, created additional subcodes to reflect participants’ responses, and compared common themes and relevant quotes to ensure intercoder reliability. Finally, lead coders (R.B.I. and A.B.B.) independently applied the final codebook across interviews and extracted quotes illustrative of emergent themes for inclusion in the manuscript. Discrepancies were resolved through discussion and consensus between lead coders. We used Dedoose qualitative coding software version 8.3.35 2020 (SocioCultural Research Consultants) for data management.
Among 21 participants from HMC, 10 PCPs and 11 staff members were interviewed, and 20 participants (95.2%) provided demographic information. The median (IQR) participant age was 38.5 (33.0-51.5) years, and 17 (85.0%) were women. There were 10 participants (50.0%) who self-identified as Asian American or Pacific Islander, 7 participants (35.0%) who self-identified as White, and 2 participants (10.0%) who self-identified as Black or African American; 1 participant self-identified as Hispanic (5.0%), and 19 participants self-identified as non-Hispanic (95.0%). Among participants, 9 individuals (45.0%) spent more than 75% of their time providing patient care, and the median (IQR) time in practice was 8 (4-24) years (Table 1). Our qualitative content analysis found that barriers and facilitators to colonoscopy completion fell into 3 major themes: (1) environment: social determinants of health, (2) environment: organizational factors, and (3) cognitive factors, including but not limited to patient expectations, patient self-efficacy, and behavioral capacity as described to clinicians. Several subthemes were also identified and are summarized in the following sections. Representative quotes for clinician-identified barriers, facilitators, and potential solutions are summarized in Table 2.
Topics related to social determinants of health among patients were the most common barriers to colonoscopy completion identified by interview participants. Lack of patient transportation (12 participants [57.1%]), language barriers (11 participants [52.4%]), and homelessness (8 participants [38.1%]) were among the most frequently reported factors. Participants remarked that patients frequently lacked access to individuals who could accompany them or drive them to and from the endoscopy unit. A substantial proportion of patients required an interpreter, and study participants were concerned about the accuracy of interpretations given the intricacies of colonoscopy completion. For patients experiencing homelessness, participants noted that the lack of access to telephones for colonoscopy instructions and restrooms to complete bowel preparation were significant challenges to colonoscopy completion.
The most frequently reported organizational barriers were lack of care coordination between primary and specialty care clinics (6 participants [28.6%]), staffing shortages (4 participants [19.0%]), and the COVID-19 pandemic (2 participants [9.5%]). Participants highlighted that clinical and regulatory procedures (eg, gastroenterology referral reviews and insurance approvals) were associated with interrupted communications between primary and specialty care and barriers to colonoscopy completion. Participants also noted that inconsistent workflows for folllow-up of abnormal FIT results across the health system, multiple steps in colonoscopy coordination, and employee turnover owing to the academic environment were associated with delayed colonoscopy completion.
Physicians and staff members reported patient cognitive factors as a common barrier to colonoscopy completion. These were most commonly associated with patient challenges with procedure bowel preparation (13 participants [61.9%]), limited health literacy (10 participants [47.6%]), and fear of the procedure or a cancer diagnosis (9 participants [42.9%]). Participants stated that among older patients and those with impaired mobility or multiple medical problems, lack of confidence in their ability to complete bowel preparation was a significant barrier to colonoscopy completion. Participants also expressed that many patients did not understand the significance of an abnormal FIT result or the importance of a follow-up colonoscopy.
When participants were asked about facilitators that addressed social determinants of health barriers, interpretation services (10 participants [47.6%]), insurance assistance (6 participants [28.6%]), and transportation assistance (5 participants [23.8%]) were most frequently reported. In 1 clinic, a participant noted that having interpreters who were more familiar with gastrointestinal procedures was associated with improved patient knowledge and colonoscopy completion. Another participant highlighted that having a dedicated financial counselor in the clinic was associated with streamlined colonoscopy referrals and procedures.
The most frequently reported organizational facilitators included having adequate staffing, specifically patient care coordinators (14 participants [66.7%]); care coordination across primary and specialty care clinics (12 participants [57.1%]); and patient appointment reminders (7 participants [33.3%]). Participants shared that during periods of adequate staffing, patient care coordinators performed patient navigation activities, including assisting with scheduling CRC screening tests and follow-up of abnormal screening results. Interview participants who were patient care coordinators also discussed how they leveraged health system knowledge and relationships to assist patients. For example, they connected patients with social workers to assist with logistical barriers, including access to health insurance and transportation.
The most frequently reported facilitators that addressed cognitive barriers to colonoscopy completion were scheduling in-person follow-up appointments (10 participants [47.6%]), general patient education (7 participants [33.3%]), and specific bowel preparation education (2 participants [9.5%]). Participants stated that setting patient expectations concerning FIT-based CRC screening (eg, informing patients about the 2-step nature of stool-based CRC screening) was associated with improved follow-up of abnormal FIT results. Participants also noted that for patients who were experiencing homelessness or whose primary language was not English, scheduling an in-person visit to review FIT results and introducing bowel prep instructions were associated with improved ability among staff members to schedule follow-up colonoscopy appointments during those visits and patient empowerment to complete the colonoscopy.
To determine clinician-identified barriers and facilitators to colonoscopy completion among patients in a safety net health care system undergoing CRC screening with an abnormal FIT result, we conducted a qualitative study using semistructured interviews of PCPs and staff members. Our analysis found that barriers to follow-up colonoscopy completion included social determinants of health (eg, lack of patient transportation, language barriers, and homelessness), organizational factors (eg, lack of care coordination, staffing shortages, and COVID-19–related practice changes), and patient cognitive factors (eg, challenges with bowel preparation, health literacy, and fear of colonoscopies). Our analysis also found that existing resources that addressed these barriers (eg, insurance assistance, appointment reminders, and bowel preparation education) were associated with improved colonoscopy completion but were insufficient to meet the recommended follow-up colonoscopy goal of 80%.23 The strengths of this study are its diverse participant population, whose practice setting fills an important void in the existing literature, and the qualitative study design, which allowed for detailed inquiry not otherwise possible through EHR review.
Colonoscopy completion is a complex process that may be especially challenging for patients in safety net health systems who experience fragmented care. Owing to socioeconomic factors, patients in safety net health care systems are less likely to receive follow-up specialty care compared with patients in higher-income groups.24 Through EHR analysis, we previously reported that lack of clinician referral, complex medical and social issues, and missed colonoscopy appointments after scheduling were associated with a lack of colonoscopy completion after abnormal FIT results in a safety net health system.10 While 2 studies from 202113,14 signaled that patient navigation may be associated with improved colonoscopy completion, qualitative studies of clinician-identified barriers that may inform interventions to further improve follow-up colonoscopy completion are limited.25-27 Through semistructured clinician interviews, our study extends the existing literature by identifying potential areas of intervention within safety net health systems at the patient level (eg, patient transportation), clinician level (eg, patient education), and health system level (eg, primary and specialty care coordination).
From 2010 to 2016, Kaiser Permanente Northern California, an integrated managed care organization, implemented several strategies to improve follow-up colonoscopy completion. Over 10 years, the organization hired additional gastroenterology personnel to expand endoscopy capacity, created a central registry of abnormal FIT results, standardized outreach through patient navigation, designated an individual responsible for tracking patients with abnormal FIT results, assigned follow-up of abnormal FIT results to gastroenterology departments, mailed certified letters to patients who did not respond to navigators, and adopted a quality metric to achieve 80% follow-up colonoscopy completion within 30 days of an abnormal FIT. These combined strategies were associated with an increase in follow-up colonoscopy completion from 73% to 85%.28 While it may be challenging for safety net health systems and FQHCs to replicate these efforts, our study suggests potential patient-level, clinician-level, and system-level strategies that may be adopted in resourced health care settings with lower resource levels that frequently use FIT for CRC screening.
Inadequate follow-up colonoscopy has been well described in safety net health systems, but few interventions have been evaluated for these settings. In the Los Angeles County Department of Health Services, an integrated safety net system, implementation of a patient navigation program was associated with an increase in colonoscopy completion after abnormal FIT results by 5.4% (40.6% to 46%).14 In the San Francisco Health Network, an integrated safety net system, we identified 3 trends in clinics with increased rates of follow-up colonoscopy completion 1-year after an abnormal FIT result: (1) Higher-performing clinics used registries to track patients with abnormal FIT results until colonoscopy completion. (2) Higher-performing clinics assigned at least 2 team members to communicate abnormal FIT results to patients. (3) Team members responsible for communicating FIT results consistently included a nurse and medical assistant.29 Our study adds qualitative perspectives from PCPs and staff members to refine interventions in safety net health care systems and similar settings with limited resources and may assist health systems in prioritizing resources to support colonoscopy completion in these settings.
Our study highlights several potential opportunities to improve follow-up colonoscopy completion among patients in safety net health care systems with abnormal FIT results (Table 2). For example, rideshare interventions have been explored to address transportation barriers in primary care settings with mixed results,30,31 but rideshare interventions have not yet been explored for colonoscopy completion due to associated procedural sedation. Optimizing rideshare use for colonoscopy may address transportation barriers identified in this study. Additionally, as health systems explore value-based models of care, this creates opportunities to increase patient care coordination through population health management to improve follow-up colonoscopy completion. For example, having gastroenterology, rather than primary care, directly follow up on abnormal stool-based screening test results has been associated with decreased colonoscopy wait times.32 Such a model could improve familiarity and communication between patient care coordinators in primary care and gastroenterology clinics and improve follow-up colonoscopy completion.33
This study has several limitations. First, we interviewed a subset of key informants who were involved in the care of patients with abnormal FIT results. Given that qualitative studies often rely on smaller samples than quantitative studies, it is possible that the barriers and facilitators identified by participants may differ from what those who were not interviewed would identify. Second, our study was conducted in an urban safety net county teaching hospital, and given this unique patient population, our findings may not be generalizable to different primary care settings. Third, while patient interviews to complement our findings are ongoing, we did not conduct clinician-patient dyad interviews, and it is possible that in dyad conversations, patients would have identified different barriers and facilitators than their clinicians did.
In this qualitative study of safety net health system PCPs and staff members, we identified barriers to follow-up colonoscopy completion, including environmental factors (ie, social determinants of health and organizational factors) and patient cognitive factors. Participants stated that resources that addressed these barriers (eg, insurance assistance, appointment reminders, and bowel preparation education) were associated with improved colonoscopy completion, but the facilitators identified have yet to be systematically implemented or evaluated. 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.
Accepted for Publication: June 1, 2021.
Published: August 10, 2021. doi:10.1001/jamanetworkopen.2021.20159
Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Issaka RB et al. JAMA Network Open.
Corresponding Author: Rachel B. Issaka, MD, MAS, Clinical Research Division, Fred Hutchinson Cancer Research Center, 1100 Fairview Ave N, M/S: M3-B232, Seattle, WA 98109 (email@example.com).
Author Contributions: Dr Issaka had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: Issaka, Chew, Weiner, Ramsey.
Acquisition, analysis, or interpretation of data: Issaka, Bell-Brown, Snyder, Atkins, Weiner, Strate, Inadomi.
Drafting of the manuscript: Issaka.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: Issaka.
Obtained funding: Issaka.
Administrative, technical, or material support: Issaka, Bell-Brown, Snyder, Atkins, Chew, Strate, Inadomi.
Supervision: Issaka, Chew, Inadomi, Ramsey.
Conflict of Interest Disclosures: None reported.
Funding/Support: Research reported in this publication was supported by grant K08CA241296 to Dr Issaka from the National Cancer Institute of the National Institutes of Health.
Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
Disclaimer: The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
Additional Contributions: We thank the interview participants who shared their experiences with us.