Barriers and facilitators to colonoscopy completion

From the Issaka Group, Division of Public Health Sciences

Colorectal cancer (CRC) screening is underutilized, especially among racial/ethnic minority and low-income groups. Stool-based testing is an effective screening tool and in safety net health care settings which care for racial/ethnic and low-income populations; CRC screening rates improve when fecal immunochemical test (FIT) is provided alongside colonoscopy. About 3.4% of patients with an abnormal FIT result are diagnosed with CRC; unfortunately, a delayed colonoscopy is associated with increased CRC mortality.  The Issaka group, from the Division of Public Health Sciences, found that at Harborview Medical Center, a safety net health care system, only 41% of patients from 2014 to 2018 completed a colonoscopy within a year of their abnormal stool-based test result. Rates similar to other safety-net health systems. The completion of a colonoscopy involves the connecting, planning, and coordinate among patients, clinicians, and the health care system. Health care professionals at Harborview Medical Center’s goal is to improve follow-up colonoscopy completion. However, evidence-based interventions to address this problem are essential. The missing knowledge gap can be filled via qualitative studies and by integrating these findings into interventions, the 80% of the follow-up goal can be achieved. The Issaka Group chronicled and explained clinician-identified barriers and facilitators to colonoscopy completion among patients with abnormal FIT results. Dr. Issaka, the first author, noted: “Our research team reflects the deep expertise across the cancer consortium. This work was enhanced by the clinical expertise of colleagues at Harborview Medical Center and the research expertise at the Fred Hutch and the University of Washington.” The study is published in JAMA Network Open.

Participants consisted of primary care physicians and staff members employed by Harborview Medical Center; they were recruited from the 7 Harborview Medical Center primary care clinics. The objective of the interviews was to identify possible barriers and facilitators not available in electronic health records. Three authors conducted and recorded in-person or secure conference interviews from February to December 2020.  Using an inductive approach, coders separately reviewed the same transcribed interviewer and established subcodes for the participants’ responses. They also compared common themes and applicable quotes for reliability. Next, the lead coders tested the finalized codes across interviews and selected quotes relevant of emergent themes. The sample population consisted of 21 participants from Harborview Medical Center, 10 primary care physicians and 11 staff members. 

Graphical Representation of Scheduled Colonoscopy
Scheduled Colonoscopy

The analyses identified three major themes and several subthemes to follow-up colonoscopy completion: social determinants of health (lack of patient transportation, language barriers, and homelessness), organizational factors (lack of care coordination, staffing shortages, and COVID-19 related practice changes), and patient cognitive factors (challenges with bowel preparation education, health literacy, and fear of colonoscopies).  The analyses described other themes that could increase colonoscopy completion but were unable to influence follow-up rates to reach 80%:  insurance assistance, appointment reminders, and bowel preparation education.

The process of colonoscopy completion is complicated, especially for patients in safety net health systems.  This study adds to the current literature by establishing patient-level areas of intervention within safety net health systems.  Dr. Issaka explained: "In our study, lack of transportation, lack of care coordination between primary and specialty care, and challenges with the bowel prep were the most frequently cited barriers to colonoscopy completion. While not entirely surprising, our study emphasizes the importance of treating stool-based CRC screening tests as one step in a two-part screening process. I cannot over-emphasize the importance of dedicating resources to ensuring that the entire process is completed to effectively decrease the risk of colorectal cancer." 

This research was supported by the National Cancer Institute of the National Institutes of Health.

Fred Hutch/UW Cancer Consortium members Rachel B. Issaka, Bryan Weiner, John M. Inadomi, and Scott D. Ramsey contributed to this work.

Issaka RB, Bell-Brown A, Snyder C, Atkins DL, Chew L, Weiner BJ, Strate L, Inadomi JM, Ramsey SD. Perceptions on Barriers and Facilitators to Colonoscopy Completion After Abnormal Fecal Immunochemical Test Results in a Safety Net System. JAMA Network Open. 2021 Aug 2;4(8):e2120159-.: doi:10.1001/jamanetworkopen.2021.20159.