Inadequate Utilization of Diagnostic Colonoscopy Following Abnormal FIT Results in an Integrated Safety-Net System.
The effectiveness of stool-based colorectal cancer (CRC) screening is contingent on colonoscopy completion in patients with an abnormal fecal immunochemical test (FIT). Understanding system and patient factors affecting follow-up of abnormal screening tests is essential to optimize care for high-risk cohorts.



This retrospective cohort study was conducted in an integrated safety-net system comprised of 11 primary-care clinics and one Gastroenterology referral unit and included patients 50-75 years, with a positive FIT between April 2012 and February 2015.



Of the 2,238 patients identified, 1,245 (55.6%) completed their colonoscopy within 1-year of the positive FIT. The median time from positive FIT to colonoscopy was 184 days (interquartile range 140-232). Of the 13% of FIT positive patients not referred to gastroenterology, 49% lacked documentation addressing their abnormal result or counseling on the increased risk of CRC. Of the patients referred but who missed their appointments, 62% lacked documentation following up on the abnormal result in the absence of a completed colonoscopy. FIT positive patients never referred to gastroenterology or who missed their appointment after referrals were more likely to have comorbid conditions and documented illicit substance use compared with patients who completed a colonoscopy.



Despite access to colonoscopy and a shared electronic health record system, colonoscopy completion after an abnormal FIT is inadequate within this safety-net system. Inadequate follow-up is in part explained by inappropriate screening, but there is an absence of clear documentation and systematic workflow within both primary care and GI specialty care addressing abnormal FIT results.
Division of Gastroenterology, University of California, San Francisco, San Francisco, California USA.
Rachel B
RB
Issaka
Division of Gastroenterology, University of California, San Francisco, San Francisco, California USA.
Maneesh H
MH
Singh
Division of General Internal Medicine, University of California, San Francisco, San Francisco, California USA.
Sachiko M
SM
Oshima
Division of Gastroenterology, University of California, San Francisco, San Francisco, California USA.
Victoria J
VJ
Laleau
Division of Gastroenterology, University of California, San Francisco, San Francisco, California USA.
Carly D
CD
Rachocki
Department of Public Health, San Francisco, California USA.
Ellen H
EH
Chen
Division of Gastroenterology, University of California, San Francisco, San Francisco, California USA.
Lukejohn W
LW
Day
Division of General Internal Medicine, University of California, San Francisco, San Francisco, California USA.
Urmimala
U
Sarkar
Division of Gastroenterology, University of California, San Francisco, San Francisco, California USA.
Ma
M
Somsouk
D001741:Black or African American; D000368:Aged; D000553:Ambulatory Care; D000554:Ambulatory Care Facilities / Q000706:statistics & numerical data; D001213:Asian; D015331:Cohort Studies; D003113:Colonoscopy / Q000706:statistics & numerical data*; D015179:Colorectal Neoplasms / Q000175:diagnosis*; D015897:Comorbidity; D003376:Counseling; D004282:Documentation; D055088:Early Detection of Cancer; D005006:Ethnicity / Q000706:statistics & numerical data; D005243:Feces / Q000737:chemistry*; D005260:Female; D005762:Gastroenterology; D006454:Hemoglobins / Q000032:analysis*; D006630:Hispanic or Latino; D006801:Humans; D007348:Insurance, Health; D007802:Language; D016015:Logistic Models; D008297:Male; D017533:Marital Status / Q000706:statistics & numerical data; D008875:Middle Aged; D015999:Multivariate Analysis; D011320:Primary Health Care; D012017:Referral and Consultation / Q000706:statistics & numerical data*; D012189:Retrospective Studies; D012307:Risk Factors; D012495:San Francisco / Q000453:epidemiology; D012737:Sex Factors; D019966:Substance-Related Disorders / Q000453:epidemiology; D013997:Time Factors; D044465:White People
D006454:Hemoglobins