Delivery of Cervical and Colorectal Cancer Screenings During the Pandemic in Community Health Centers: Practice Changes and Recovery Strategies

Abstract

Background: The coronavirus disease 2019 pandemic led to clinical practice changes, which affected cancer preventive care delivery.

Objectives: To investigate the impact of the coronavirus disease 2019 pandemic on the delivery of colorectal cancer (CRC) and cervical cancer (CVC) screenings.

Research design: Parallel mixed methods design using electronic health record data (extracted between January 2019 and July 2021). Study results focused on 3 pandemic-related periods: March-May 2020, June-October 2020, and November 2020-September 2021.

Subjects: Two hundred seventeen community health centers located in 13 states and 29 semistructured interviews from 13 community health centers.

Measures: Monthly up-to-date CRC and CVC screening rates and monthly rates of completed colonoscopies, fecal immunochemical test (FIT)/fecal occult blood test (FOBT) procedures, Papanicolaou tests among age and sex-eligible patients. Analysis used generalized estimating equations Poisson modeling. Qualitative analysts developed case summaries and created a cross-case data display for comparison.

Results: The results showed a reduction of 75% for colonoscopy [rate ratio (RR) = 0.250, 95% CI: 0.224-0.279], 78% for FIT/FOBT (RR = 0.218, 95% CI: 0.208-0.230), and 87% for Papanicolaou (RR = 0.130, 95% CI: 0.125-0.136) rates after the start of the pandemic. During this early pandemic period, CRC screening was impacted by hospitals halting services. Clinic staff moved toward FIT/FOBT screenings. CVC screening was impacted by guidelines encouraging pausing CVC screening, patient reluctance, and concerns about exposure. During the recovery period, leadership-driven preventive care prioritization and quality improvement capacity influenced CRC and CVC screening maintenance and recovery.

Conclusions: Efforts supporting quality improvement capacity could be key actionable elements for these health centers to endure major disruptions to their care delivery system and to drive rapid recovery.

FIGURE 1

Percentage of eligible patients up-to-date with CRC (A) and CVC (B) screenings. Thick dash line represents the average of the full sample clinics and thin lines represent the trend for each recruited clinic. Clinics with <10 encounters for each month of the study period were excluded resulting in 213 clinics for CVC and 198 clinics for CRC screenings. CRC screenings include colonoscopy, FIT, and FOBT. The vertical line in March 2020 represents the onset of the pandemic. Clinic 13 in the qualitative sample is not displayed as it had <10 eligible encounters/month during the preperiod. Data were from community health centers from January 2019 to June 2021. CRC indicates colorectal cancer; CVC, cervical cancer, FIT, fecal immunochemical test, FOBT, fecal occult blood test.

FIGURE 2

Rates of colonoscopy procedures (A) and FIT/FOBT test (B), Pap (C) procedures. Rates are by 1000 eligible patients (with 95% CI for clinic variations) from January 2019 to June 2021. Rates were computed using generalized estimating equations Poisson modeling. Models accounted for temporal correlation of monthly observations within clinics through an autoregressive AR(1) correlation structure. Clinics with <10 encounters for each month were excluded resulting in 213 clinics for CVC and 198 clinics for CRC screenings. FIT indicates fecal immunochemical test, FOBT, fecal occult blood test, Pap, Papanicolaou.