Patient interventions with low-income and minorities increases colonoscopy rates

Patient interventions are necessary to achieve higher rates of colorectal cancer screening in low-income and minority patients, according to two studies in the current issue of Clinical Gastroenterology and Hepatology, the official journal of the American Gastroenterological Association (AGA) Institute.

Colonoscopy Completion in a Large Safety Net Health Care System

The first study examined patient attendance for scheduled colonoscopies at a large safety net health care system, Denver Health Medical Center. The Denver research team conducted a six-month retrospective review of outpatient endoscopy laboratory scheduling and procedure logs at the center and concluded that 41.7 percent of 817 scheduled outpatient colonoscopies were not attended by patients. Additionally, of those who came for their appointments, 30.2 percent exhibited inadequate bowel preparation.

“Our findings show that there is an enormous problem with patients in safety net health systems skipping their scheduled colonoscopies or showing up inadequately prepared, and anecdotal evidence tells us that the issue is prevalent in safety net systems across the country,” said Thomas D. Denberg, MD, PhD, of the University of Colorado Denver School of Medicine.

This is the first study to formally characterize rates of colonoscopy within a safety net health system. These systems traditionally have a large proportion of low-income and minority patients and report that their colonoscopy no-show rates are “very high.” The Denver research team indicated that the colonoscopy non-attendance rate at Denver Health is much greater than has been described for patients in non-safety-net systems in the U.S., but is comparable to other institutions that serve large numbers of low-income and minority patients.

“The big question now is how to address this issue. Because the rationale and required steps for completing colonoscopy are complex, individual intervention with patient navigators – non-clinical individuals who are specially trained to navigate the health care system – may be particularly helpful. Published accounts show that they have been very successful in minority community health centers and public hospitals in the U.S.,” Dr. Denberg concluded.

A Program to Enhance Completion of Screening Colonoscopy Among Urban Minorities

Specifically examining the role patient intervention plays in completed colonoscopy rates in urban minorities, a research team from Mount Sinai School of Medicine, New York and the City University of New York evaluated the effects of introducing patient navigators in working with urban minorities to complete colonoscopy appointments. The team provided a patient navigator to 532 colonoscopy patients to help guide them through preparation for the procedure and encourage attendance after the primary care physician recommended the procedure.

Results showed that 67 percent (353) of navigated patients proceeded with their colonoscopies, and the no-show rate among urban minorities in the study was 9.8 percent, down from the approximately 40 percent average prior to the onset of the navigator program. Inadequate bowel preparation was recognized in 5 percent of the patients screened, a decrease from the 12 percent reported in previous analysis. Reasons for non-completion included patients who wanted to speak in detail with their physician prior to the procedure or those who refused to undergo the procedure or navigation.

“We saw a substantial uptake in the colonoscopy completion rate with the introduction of a patient navigator, as well as a remarkable decline in the appointment no-show rate,” said Steven H. Itzkowitz, MD, AGAF, FACP, FACG with Mount Sinai School of Medicine. “These rates are certainly higher than those reported in other studies investigating colonoscopy follow-through in minority populations, and we attribute this to the individual intervention with the patient navigator. Our results show that introducing a patient navigator is effective in increasing colonoscopy completion rates in urban minorities, which not only directly benefits the patient, but should translate into greater efficiency and cost savings for endoscopy units. The New York City Department of Health and Mental Hygiene has embraced the patient navigator concept and is developing programs to expand this model throughout the city.”

The AGA Institute considers colonoscopy the definitive screening and treatment procedure for colorectal cancer. When detected early, colon cancer is among the most treatable of all cancers and has a five-year survival rate of 90 percent. That survival rate drops to only 10 percent when people are diagnosed with the most advanced stage of the disease (once it has spread from the colon to other organs such as the liver and lungs). An estimated 148,800 people will be diagnosed with colorectal cancer in 2008, and nearly 50,000 will die from the preventable disease.