Clinicians See Barriers to Colonoscopy Completion After Abnormal Fecal Test

By Lisa Rapaport

September 20, 2021

(Reuters Health) - Many patients who receive abnormal fecal immunochemical test results may face a variety of barriers to colonoscopy completion, including cognitive and social factors, a recent study suggests.

Researchers examined data from semi-structured interviews with 10 primary care physicians and 11 staff members who worked at a large safety-net healthcare system in Washington State. All the participants reported social determinants of health, cognitive factors, and organizational factors as potential barriers to colonoscopy completion after abnormal fecal test results.

"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," said lead study author Dr. Rachel Issaka, an assistant professor and gastroenterologist at the Fred Hutchinson Cancer Research Center and the University of Washington, in Seattle.

While the results are not entirely surprising, the findings do underscore the importance of clinician communication with patients to stress that fecal immunochemical tests are the first step in a two-step screening process, Dr. Issaka said by email.

"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," Dr. Issaka said.

More than half of the clinicians who participated in the study cited lack of transportation (57.1%) and language barriers (52.4%) as the biggest social determinants of health barriers to colonoscopy completion. Many also cited homelessness (38.1%).

Many participants also noted organizational factors such as poor communication between specialty care clinics and primary care physicians (28.6%), and staffing shortages (19.0%) as barriers to colonoscopy completion.

In addition, participants often cited cognitive factors such as patients' lack of understanding about how to perform procedural bowel prep (61.9%), and limited health literacy (47.6%) as barriers to colonoscopy completion.

When researchers asked participants to identify social determinants of health that facilitated colonoscopy completion, the most commonly cited supports were interpretation services (47.6%), insurance assistance (28.6%), and transportation assistance (23.8%).

Other facilitators to colonoscopy completion cited by participants included specialty care coordinators (66.7%), care coordination across primary care and specialty care clinics (57.1%), and patient appointment reminders (33.3%).

Several participants also identified scheduling in-person follow-up appointments (47.6%), general patient education (33.3%), and specific bowel prep education (9.5%) as potential facilitators to colonoscopy completion.

Beyond its small size, another limitation of the study is that results from one urban safety-net system might not be representative of outcomes elsewhere, the authors note in JAMA Network Open.

Even so, the results suggest that clinicians need to take the time to understand patients' life circumstances to help identify potential barriers and facilitators to colonoscopy completion, said Dr. Theodore Levin, clinical lead for colorectal cancer screening at the Permanente Medical Group and a staff physician at Kaiser Permanente Medical Center in Walnut Creek, California.

"We can't assume it's just because they are squeamish about drinking the laxative prep or the thought of someone doing a colonoscopy on them," Dr. Levin, who wasn't involved in the study, said by email.

"We need to be curious about the challenges they face to even reach our facility to have the procedure," Dr. Levin said.

SOURCE: https://bit.ly/3tTlEJN JAMA Network Open, online August 10, 2021.

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