From the 2021 HVPAA National Conference
Amanda Long (Lankenau Medical Center), Louma Rustam, Kyley Leroy, Vida Chen
Colorectal cancer (CRC) is the second most common cause of cancer-related death among both men and women in the United States . Despite compelling evidence that CRC screening improves incidence and mortality only 65.2% of eligible U.S. adults were screened according to the USPSTF guidelines as of 2018  . Screening rates remain consistently low in those with lower incomes, fewer years of formal education, under-insured, and African Americans. These groups make up the predominant population of our clinics.
Barriers and/or misconceptions that come with colonoscopy make completion of this screening method difficult in high risk populations. The fears and misconceptions associated with colonoscopy are consistent. These include difficulty scheduling, time off of work, transportation home after sedation, bowel prep, anesthesia, insurance coverage, embarrassment, and poor understanding of the procedure.
In our community-based, resident run clinic, we identified additional barriers to CRC screening. As with many resident clinics, show rates are exceptionally low. As our process is not an open access colonoscopy system, patients need to keep and show up to two separate appointments before a colonoscopy is scheduled. We identified that patients had a remarkably low show-rate to their pre-colonoscopy visit, and our goal was to improve this aspect of CRC screening.
To utilize patient education tools by using educational brochures to improve the show-rate for patients to our Gastroenterology Fellows Clinic for CRC screening completion.
This was an observational prospective study. The control arm from 5/1/2018-9/1/2018 included a total of 30 patients, and the intervention arm included a total of 48 patients from 5/1/2019-9/1/2019. Patients in the intervention arm were given a handout containing health-literacy adjusted medical information regarding the importance of screening colonoscopies by their referring provider. The primary outcome measured was compliance with the initial visit for colon cancer screening.
There were no significant differences in age, family history of colon cancer, or race between the two arms (all p-values > 0.05). The average ages for the control group and intervention group were 58 and 59, respectively. Among the control group, 77% were female and 87% were Black or African American. Among the intervention group, 50% were female and 85% were Black or African American, 6% White, and 8% other race. After controlling for sex and race, there was a statistically significant association between the intervention and completing the colonoscopy screening (adjusted OR = 0.22, p=0.014). Unfortunately, after controlling for sex and race, the odds of a completed screening in the control group was 4.55 times the odds in the intervention group. As a result, a completed screening was significantly less likely in the intervention group.
The barriers to CRC screening are unique from other cancer screenings and are magnified in vulnerable populations. Our study has shown that education alone is not enough to improve show-rate and therefore screening rates. As other studies have suggested, a multimodal system approach would likely be the most successful.
Multimodal interventions have proven to have the greatest effect on CRC screening; however, this is difficult to achieve. Our study showed that education alone is not enough to improve show rates for CRC screening in vulnerable populations.