Abnormal Colorectal Cancer Test Follow-Up: A Quality Improvement Initiative at a Federally Qualified Health Center

Abstract

Introduction/objectives: Colonoscopy completion rates after an abnormal fecal immunochemical test (FIT) are suboptimal, resulting in missed opportunities for early detection and prevention of colorectal cancer. Patient navigation and structured follow-up may improve colonoscopy completion, but implementation of these strategies is not widespread.

Methods: We conducted a quality improvement study using a Plan-Do-Study-Act (PDSA) Model to increase colonoscopy completion after abnormal FIT in a large federally qualified health center serving a diverse and low-income population. Intervention components included patient navigation, and a checklist to promote completion of key steps required for abnormal FIT follow-up. Primary outcome was proportion of patients achieving colonoscopy completion within 6 months of abnormal FIT, assessed at baseline for 156 patients pre-intervention, and compared to 208 patients during the intervention period from April 2017 to December 2019. Drop offs at each step in the follow-up process were assessed.

Results: Colonoscopy completion improved from 21% among 156 patients with abnormal FIT pre-intervention, to 38% among 208 patients with abnormal FIT during the intervention (P < .001; absolute increase: 17%, 95% CI: 6.9%-25.2%). Among the 130 non-completers during the intervention period, lack of completion was attributable to absence of colonoscopy referral for 7.7%; inability to schedule a pre-colonoscopy specialist visit for 71.5%; failure to complete a pre-colonoscopy visit for 2.3%; the absence of colonoscopy scheduling for 9.2%; failure to show for a scheduled colonoscopy for 9.2%.

Conclusions: Patient navigation and structured follow-up appear to improve colonoscopy completion after abnormal FIT. Additional strategies are needed to achieve optimal rates of completion.

Keywords: abnormal fecal immunochemical test follow-up; care coordination; colorectal cancer screening; federally qualified health center; patient navigation.

Figure 1.

Completion of abnormal FIT follow up steps among all patients with an abnormal FIT during the intervention period. Proportion of patients with abnormal FIT completing key steps in the colonoscopy completion process is depicted. Abbreviation: FIT, fecal immunochemical test.

Figure 2.

Distribution of drop-offs in the abnormal FIT follow up process among colonoscopy non-completers. Among the 130 individuals who did not complete colonoscopy after abnormal FIT, the process step accounting for the largest proportion was failure to schedule a pre-colonoscopy clinic evaluation after referral for a colonoscopy. Abbreviation: FIT, fecal immunochemical test.