A survey of primary care physicians and staff in a safety-net health care system found frequent barriers and facilitators for colonoscopy completion among patients with abnormal results on a fecal immunochemical test.
Researchers surveyed 21 primary care physicians and staff at Harborview Medical Center, a safety-net county teaching hospital system in Seattle that has seven primary care clinics providing care to historically underserved populations. Semistructured interviews were conducted from February to December 2020. The study results were published Aug. 10 by JAMA Network Open.
Survey respondents reported that social determinants of health were the most common barriers to colonoscopy completion among patients, including lack of patient transportation (57.1%), language barriers (52.4%), and homelessness (38.1%). Organizational barriers included lack of care coordination between primary and specialty care clinics (28.6%), staffing shortages (19.0%), and the COVID-19 pandemic (9.5%). Patient cognitive factors were also reported as barriers, including challenges with procedure bowel preparation (61.9%), limited health literacy (47.6%), and fear of the procedure or a cancer diagnosis (42.9%). Older patients often did not proceed to colonoscopy because impaired mobility or multiple medical problems affected their confidence in their ability to complete bowel preparation, the survey found.
The survey respondents reported that patients were more likely to complete colonoscopy after a positive FIT result if interpretation services (47.6%), insurance assistance (28.6%), and transportation assistance (23.8%) were available. One participant noted an association between interpreters who were more familiar with gastrointestinal procedures and improved patient knowledge and colonoscopy rates, and another noted colonoscopy referrals and procedures were streamlined by having a dedicated financial counselor in the clinic.
Organizational factors associated with improved colonoscopy rates included sufficient staffing, specifically patient care coordinators (66.7%); care coordination across primary and specialty care clinics (57.1%); and patient appointment reminders (33.3%). Better rates were also associated with factors that addressed cognitive barriers, including in-person follow-up appointments (47.6%), general patient education (33.3%), and specific bowel preparation education (9.5%). Survey respondents also said it was important to ensure patients understood the two-step nature of stool-based colorectal cancer screening.
“Incorporating clinician-identified factors into multilevel interventions may be associated with improved colonoscopy completion among patients with abnormal FIT results and help address one of the most persistent challenges in cancer prevention and control for safety net and other medically underserved populations,” the authors concluded.