Operationalizing a Rideshare Intervention for Colonoscopy Completion: Barriers, Facilitators, and Process Recommendations

IntroductionTransportation is a common barrier to colonoscopy completion for colorectal cancer (CRC) screening. The study aims to identify the barriers, facilitators, and process recommendations to implement a rideshare non-emergency medical transportation (NEMT) intervention following colonoscopy completion within a safety-net healthcare setting.MethodsWe used informal stakeholder engagement, story boards—a novel user-centered design technique, listening sessions and the nominal group technique to identify the barriers, facilitators, and process to implementing a rideshare NEMT program following colonoscopy completion in a large safety-net healthcare system.ResultsBarriers to implementing a rideshare NEMT intervention for colonoscopy completion included: inability to expand an existing NEMT program beyond Medicaid patients and lack of patient chaperones with rideshare NEMT programs. Facilitators included: commercially available rideshare NEMT platforms that were lower cost and had shorter wait times than the alternative of taxis. Operationalizing and implementing a rideshare NEMT intervention in our healthcare system required the following steps: 1) identifying key stakeholders, 2) engaging stakeholder groups in discussion to identify barriers and solutions, 3) obtaining institutional sign-off, 4) developing a process for reviewing and selecting a rideshare NEMT program, 5) executing contracts, 6) developing a standard operating procedure and 7) training clinic staff to use the rideshare platform.DiscussionRideshare NEMT after procedural sedation is administered may improve colonoscopy completion rates and provide one solution to inadequate CRC screening. If successful, our rideshare model could be broadly applicable to other safety-net health systems, populations with high social needs, and settings where procedural sedation is administered.

Odds of Incomplete Colonoscopy in Colorectal Cancer Screening Based on Socioeconomic Status

The aim of this study is to investigate the association between socioeconomic status (SES) and the risk of having an incomplete colonoscopy (IC) in the Danish Colorectal Cancer (CRC) Screening Program. In this register-based study we included 71,973 participants who underwent colonoscopy after a positive fecal immunochemical test in the Danish CRC Screening Program. The main exposure, SES, was defined by income and education, and the outcome by complete or incomplete colonoscopy. Among the participants, 5428 (7.5%) had an incomplete colonoscopy. The odds ratio (OR) for ICs due to inadequate bowel preparation was 1.67 (95% CI: 1.46; 1.91) for income in the 1 quartile compared to income in the 4th quartile. ORs for income in the 2nd quartile was 1.38 (95% CI: 1.21; 1.56) and 1.17 (95% CI: 1.03; 1.33) for income in the 3rd quartile. For the educational level, an association was seen for high school/vocational education with an OR of 0.87 (95% CI: 0.79; 0.97) compared to higher education. For ICs due to other reasons, the level of income was associated with the risk of having an IC with an OR of 1.19 (95% CI: 1.05; 1.35) in the 1st quartile and an OR of 1.19 (95% CI: 1.06; 1.34) in the 2nd quartile. For the educational level, there were no significant associations. Low income is associated with high risk of having an IC, whereas educational level does not show the same unambiguous association.

Epidemiologic Disparities in Colon Cancer Screening and Adherence during the COVID-19 Pandemic: A Retrospective Cohort Analysis

Background: Colorectal cancer (CRC) is the second-leading cause of death in the US. Despite the National Colorectal Roundtable goal of achieving 80% adherence, CRC screening remains underutilized, especially in the underinsured populations. Screening programs have been heavily disrupted during the COVID-19 pandemic. Aim: This research was performed to explore the impact of the pandemic on the existing ethnic and gender disparities prevalent in CRC screening. Methods: Patients were identified 1 year before and after COVID-19 precautions began, using March 1, 2020, as the inflection point. For each year, the primary inclusion criterion was an ordered colonoscopy. The outcome of interest was a colonoscopy performed. Differences by year and race were assessed using Chi-square analysis. A cohort of 1413 patients between age 45 and 75 for whom a colonoscopy was ordered was selected from EHR at a single large institution. 897 patients were in the pre-COVID group, and 516 were in the post-COVID group. Results: There was a 51% reduction in screening colonoscopies performed. White patients had a decrease of 49%, and African Americans had a 55% reduction. Stool testing increased from 47% prior to the pandemic to 94% during the pandemic representing a greater than 100% increase in stool testing uptake. Conclusion: The true impact of COVID-19 on colorectal cancer is yet to be uncovered as future mortality estimates from CRC are ongoing. Due to the widespread closure of endoscopy centers and delay in screening, we believe that the pandemic worsened the screening disparities most prevalent among minority populations. Our retrospective analysis over the last two years points to the drastic reduction of screening for all races, and especially for African Americans. As life gradually returns to normal, it would be interesting to see how the past year has impacted the incidence and prevalence of CRC.

Mediators of screening uptake in a colorectal cancer screening intervention among Hispanics

Background Colorectal cancer (CRC) is the second leading cause of cancer deaths in the USA. Although a number of CRC screening tests have been established as being effective for CRC prevention and early detection, rates of CRC screening test completion in the US population remain suboptimal, especially among the uninsured, recent immigrants and Hispanics. In this study, we used a structural equation modelling approach to identify factors influencing screening test completion in a successful CRC screening program that was implemented in an uninsured Hispanic population. This information will enhance our understanding of influences on CRC screening among historically underscreened populations. Methods We used generalized structural equation models (SEM) utilizing participant reported information collected through a series of surveys. We identified direct and indirect pathways through which cofactors, CRC knowledge and individual Health Belief Model constructs (perceived benefits, barriers, susceptibility, fatalism and self-efficacy) and a latent psychosocial health construct mediated screening in an effective prospective randomized CRC screening intervention that was tailored for uninsured Hispanic Americans. Results Seven hundred twenty-three participants were eligible for inclusion; mean age was 56 years, 79.7% were female, and 98.9% were Hispanic. The total intervention effect was comparable in both models, with both having a direct and indirect effect on screening completion (n = 715, Model 1: RC = 2.46 [95% CI: 2.20, 2.71, p < 0.001]; n = 699, Model 2 RC =2.45, [95% CI: 2.18, 2.72, p < 0.001]. In Model 1, 32% of the overall effect was mediated by the latent psychosocial health construct (RC = 0.79, p < 0.001) that was in turn mainly influenced by self-efficacy, perceived benefits and fatalism. In Model 2, the most important individual mediators were self-efficacy (RC = 0.24, p = 0.013), and fatalism (RC = 0.07, p = 0.033). Conclusion This study contributes to our understanding of mediators of CRC screening and suggests that targeting self-efficacy, perceived benefits and fatalism could maximize the effectiveness of CRC screening interventions particularly in Hispanic populations.

Cause of Death, Mortality and Occult Blood in Colorectal Cancer Screening

Fecal hemoglobin (f-Hb) detected by the guaiac fecal occult blood test (gFOBT) may be associated with mortality and cause of death in colorectal cancer (CRC) screening participants. We investigated this association in a randomly selected population of 20,694 participants followed for 33 years. We followed participants from the start of the Hemoccult-II CRC trial in 1985–1986 until December 2018. Data on mortality, cause of death and covariates were retrieved using Danish national registers. We conducted multivariable Cox regressions with time-varying exposure, reporting results as crude and adjusted hazard ratios (aHRs). We identified 1766 patients with at least one positive gFOBT, 946 of whom died in the study period. Most gFOBT-positive participants (93.23%) died of diseases unrelated to CRC and showed higher non-CRC mortality than gFOBT-negative participants (aHR: 1.20, 95% CI 1.10–1.30). Positive gFOBT participants displayed a modest increase in all-cause (aHR: 1.28, 95% CI: 1.18–1.38), CRC (aHR: 4.07, 95% CI: 3.00–5.56), cardiovascular (aHR: 1.22, 95% CI: 1.07–1.39) and endocrine and hematological mortality (aHR: 1.58, 95% CI: 1.19–2.10). In conclusion, we observed an association between positive gFOBT, cause of death and mortality. The presence of f-Hb in the gFOBT might indicate the presence of systemic diseases.

Additional offer of sigmoidoscopy in colorectal cancer screening in Germany: rationale and protocol of the decision-analytic modelling approach in the SIGMO study

IntroductionIn Germany, statutory insured persons are entitled to a stool test (faecal immunochemical test (FIT)) or colonoscopy for colorectal cancer (CRC) screening, depending on age and sex, yet participation rates are rather low. Sigmoidoscopy is a currently not available screening measure that has a strong evidence base for incidence and mortality reduction. Due to its distinct characteristics, it might be preferred by some, who now reject colonoscopy. The objective of this study is to estimate the economic consequences of the additional offer of sigmoidoscopy for CRC screening in Germany compared with the present screening practice while considering the preferences of the general population.Methods and analysisA decision-analytic modelling approach will be developed that compares the present CRC screening programme in Germany (FIT, colonoscopy) with a programme extended by sigmoidoscopy from a societal perspective. A decision tree and Markov model will be combined to assess both short-term and long-term effects, such as CRC and adenoma detection rates, the number of CRC cases, CRC mortality as well as complications. The incremental cost per quality-adjusted life year gained for each alternative will be calculated. The model will incorporate the general population’s preferences based on a discrete choice experiment. Further, input parameters will be taken from the literature, the German cancer registry and health insurance claims data.Ethics and disseminationEthical approval for the study was obtained from the Ethics Committee of Hannover Medical School (ID: 8671_BO_K_2019). The findings of the study will be published in peer-reviewed journals and presented at national and/or international conferences.Trial registration numberDRKS00019010.

Persistent Barriers to Colorectal Cancer Screening Completion Amid Centralized Outreach: A Mixed Methods Study

Purpose To understand patient experiences and persistent barriers to colorectal cancer (CRC) screening amid centralized outreach at urban family medicine practices. Approach Following a pragmatic trial assessing mailed fecal immunochemical test (FIT) outreach, we invited a subset of participants to complete a semi-structured qualitative interview and structured questionnaire. Setting Single urban academic healthcare system. Participants Sixty patients who were eligible and overdue for CRC screening at the time of trial enrollment. Method Using Andersen’s Behavioral Model, we developed an interview guide to systematically assess factors shaping screening decisions and FIT uptake. Close-ended responses were analyzed using descriptive statistics. Qualitative data were analyzed using the constant comparative method. Results Most participants (82%) self-reported that they had ever completed any modality of CRC screening, and nearly half (43%) completed the mailed FIT during the trial. Most patients (60%) preferred FIT to colonoscopy due to its private, convenient, and non-invasive nature; however, persistent barriers related to screening beliefs including fear of test results and cancer treatment still prevented some patients from completing any form of CRC screening. Conclusions Mailed FIT can overcome many structural barriers to CRC screening, yet clear communication and follow-up amid centralized outreach are essential. For some patients, tailored outreach or navigation to address screening-related fears or other screening beliefs may be needed to ensure timely completion of CRC screening.

Prevalence of Colorectal Cancer Screening Among Hispanic Subgroups in the United States: NHIS 2010 and 2015 Data

Introduction: Much of the data related to colorectal cancer (CRC) disease burden among Hispanics is grouped together. The purpose of our study was to better understand the current screening uptake across Hispanic subgroups. Methods: Data from the CRC screening portion of the 2010 and 2015 Adult Cancer Control Module of the National Hispanic Interview Survey (NHIS). A univariate and multivariable analysis were conducted. Results: Total sample size: 7,389. Subgroup with most participants: Mexican-American. For all Hispanics, 24% were up to date with CRC screening. In adjusted analyses, variables significantly associated with being up to date among all Hispanics were: older age (prevalence ratio [PR] = 1.03; p = <.0001), female sex (PR = 1.28; p = 0.003), more than high school education (PR = 1.25; p = 0.006), annual household income between $45,000 and $74,999 ( PR = 1.51; p = 0.018), living in the United States for 15 years or more (PR = 1.45; p = 0.039), having health insurance (PR = 2.06; p = <.0001), and having a first-degree relative with CRC (PR = 1.35; p < .0001). Discussion: Various social determinants of health were found to be associated with increased prevalence of being up to date with CRC screening among different Hispanic subgroups. Conclusion: These findings serve as a starting point to develop interventions tailored to specific Hispanic subgroups with social determinants of health, namely low socioeconomic status, at the forefront of development.

A Culturally Adapted Colorectal Cancer Education Video for the Somali Community in Minnesota: A Pilot Investigation

Purpose This study aims to develop and test feasibility of a colorectal cancer (CRC) education video appropriate for Somali immigrants. Design One-group pretest–posttest design. Setting Minneapolis, MN. Sample Thirty-one Somali men (mean age = 60.6; SD = 13.0). Intervention A CRC education video was developed in the Somali language with Somali community partners. Participants were invited to a workshop and watched the video. Measures Levels of understanding about CRC and screening were assessed before vs after the video. Analysis Binomial tests were conducted to examine changes in level of understanding. Results Analysis on pre–post, within-person changes in understanding about cancer, and CRC screening showed that proportions with a positive change in understanding risks of cancer (80%) and benefits of CRC screening (90%) were significantly higher than expected if the video had no effect (50%; P = .012, P < .001, respectively). Ninety-three percent of participants agreed that the video contained useful information. Conclusion These results provide evidence of usefulness of culturally tailored videos to facilitate CRC screening in the Somali community. Results of this study were limited by a small sample size and lack of a control group.