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Description: The American College of Physicians (ACP) developed this guideline to provide clinical recommendations on the role of colonoscopy for diagnostic evaluation of colorectal cancer (CRC) after a presumed diagnosis of acute left-sided colonic diverticulitis and on the role of pharmacologic, nonpharmacologic, and elective surgical interventions to prevent recurrence after initial treatment of acute complicated and uncomplicated left-sided colonic diverticulitis. This guideline is based on the current best available evidence about benefits and harms, taken in the context of costs and patient values and preferences.Methods: The ACP Clinical Guidelines Committee (CGC) based these recommendations on a systematic review on the role of colonoscopy after acute left-sided colonic diverticulitis and pharmacologic, nonpharmacologic, and elective surgical interventions after initial treatment. The systematic review evaluated outcomes rated by the CGC as critical or important. This guideline was developed using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) method.Target Audience and Patient Population: The target audience is all clinicians, and the target patient population is adults with recent episodes of acute left-sided colonic diverticulitis.Recommendation1: ACP suggests that clinicians refer patients for a colonoscopy after an initial episode of complicated left-sided colonic diverticulitis in patients who have not had recent colonoscopy (conditional recommendation; low-certainty evidence).Recommendation2: ACP recommends against clinicians using mesalamine to prevent recurrent diverticulitis (strong recommendation; high-certainty evidence).Recommendation3: ACP suggests that clinicians discuss elective surgery to prevent recurrent diverticulitis after initial treatment in patients who have either uncomplicated diverticulitis that is persistent or recurs frequently or complicated diverticulitis (conditional recommendation; low-certainty evidence). The informed decision whether or not to undergo surgery should be personalized based on a discussion of potential benefits, harms, costs, and patient's preferences. [ABSTRACT FROM AUTHOR]

To examine the healthcare costs associated with colorectal cancer (CRC) screening and the frequency and costs of events potentially related to colonoscopy among average-risk adults. In this cohort study, adults (ages 50–75 years) with CRC screening between 1/1/2014 and 6/30/2019 (index = earliest test) were selected from the IBM MarketScan Research databases. Individuals at above-average risk for CRC or with prior CRC screening were excluded. Frequency of utilization was reported by screening type: colonoscopy, fecal immunochemical test (FIT), fecal occult blood test (FOBT), multi-target stool DNA (mt-sDNA). For colonoscopy, frequency and costs of potential events were reported overall, by event type, and by an individual event in the 30 days after colonoscopy. Among the 333,306 average-risk adults, colonoscopy was the most common CRC screening modality (70.6%), followed by FIT (17.7%), FOBT (8.1%), and mt-sDNA (3.2%). The mean cost of a colonoscopy procedure was $2,125 and the mean out-of-pocket costs were $79. Serious gastrointestinal (GI) events were observed in 1.3% of individuals with colonoscopy, 1.9% had other GI events, and 1.2% had an incident cardiovascular event. Mean event-related costs were $2,631 among individuals with a serious GI event, $1,774 among individuals with any other GI event, and $4,234 among individuals with a cardiovascular event. This study provides updated and more detailed information regarding the costs of CRC screening and potential colonoscopy events based on a comprehensive review of a robust claims dataset. [ABSTRACT FROM AUTHOR]

Purpose: Obesity represents a well-known risk factor for metabolic-dysfunction associated fatty liver disease (MAFLD) and its progression towards cirrhosis. The aim of this study is to estimate the proportion of potential candidates to a bariatric surgery intervention that has an elevated liver stiffness on vibration-controlled transient elastography (VCTE). Materials and Methods: This is a cross-sectional study performed using data obtained during the 2017–2018 cycle of the National Health and Nutrition Examination Survey. Potential candidates for a bariatric surgery intervention from the general US population were identified by applying criteria from international guidelines. All included participants were evaluated by VCTE. A controlled attenuation parameter (CAP) value ≥ 288 dB/m was considered indicative of steatosis while liver stiffness measurement (LSM) was considered elevated if ≥ 9.7 kPa. Multivariable logistic regression models were fitted to identify independent predictors of both outcomes. Results: A total of 434 participants were included (mean age 42.9 ± 0.6 years; 54.4% women). Among them, 76.7% (95% CI 71.7–81.0) had steatosis, while 23.1% (95% CI 17.8–29.3) had an elevated LSM. Male sex, older age, γ-glutamyltranspeptidase levels, and body mass index (BMI) were independent predictors of steatosis, while BMI was the only independent predictor of elevated LSM. Non-Hispanic black participants were protected from both outcomes, while other ethnicities were not. Conclusion: The prevalence of elevated LSM is high in potential candidates for a bariatric surgery intervention. Accurate screening for occult advanced liver disease might be indicated in this patient population. [ABSTRACT FROM AUTHOR]

Introduction: Colorectal cancer is the second leading cause of cancer deaths in the USA, and screening tests are underutilized. The aim of this study was to determine the proportion of individuals at average risk who utilized a recommended initial screening test in a universal healthcare coverage system.Materials and Methods: This is a retrospective cohort study of active duty and retired military members as well as civilian beneficiaries of the Military Health System. Individuals born from 1960 to 1962 and eligible for full benefits on their 50th birthday were evaluated. Military rank or rank of benefits sponsor was used to determine socioeconomic status. Adherence to the U.S. Preventive Services Task Force guidelines for initial colorectal cancer screening was determined using "Current Procedural Terminology" and "Healthcare Common Procedure Coding System" codes for colonoscopy, sigmoidoscopy, fecal occult blood test, and fecal immunohistochemistry test. Average risk individuals who obtained early screening ages 47 to 49 were also identified.Results: This study identified 275,665 individuals at average risk. Of these, 105,957 (38.4%) adhered to screening guidelines. An additional 19,806 (7.2%) individuals were screened early. Colonoscopy (82.7%) was the most common screening procedure. Highest odds of screening were associated with being active duty military (odds ratio [OR] 3.63, 95% confidence interval [CI] 3.43 to 3.85), having highest socioeconomic status (OR 2.37, 95% CI 2.31 to 2.44), and having managed care insurance (OR 4.36, 95% CI 4.28 to 4.44).Conclusions: Universal healthcare coverage does not ensure initial colorectal cancer screening utilization consistent with guidelines no does it eliminate disparities. [ABSTRACT FROM AUTHOR]

Objective: It is not known whether patients' ratings of the quality of healthcare services they receive truly correlate with the quality of care from their providers. Understanding this association can potentiate improvement in healthcare delivery. We evaluated the association between patients' ratings of the quality of healthcare services received and uptake of colorectal cancer (CRC) screening.Subjects and Methods: We used 2 iterations of the Health Information National Trends Survey (HINTS) of adults in the USA. HINTS 2007 (4,007 respondents; weighted population = 75,397,128) evaluated whether respondents were up to date with CRC screening while HINTS 4 cycle 3 (1,562 respondents; weighted population = 76,628,000) evaluated whether participants had ever received CRC screening in the past. All included respondents from both surveys were at least 50 years of age, had no history of CRC, and had rated the quality of healthcare services that they had received at their healthcare provider's office in the previous 12 months.Results: HINTS 2007 data showed that respondents who rated their healthcare as good or fair/poor were significantly less likely to be up to date with CRC screening compared to those who rated their healthcare as excellent. We found comparable results from analysis of HINTS 4 cycle 3 data with poorer uptake of CRC screening as the healthcare quality ratings of respondents reduced.Conclusion: Our study suggests that patients who reported receiving lower quality of healthcare services were less likely to have undergone and be compliant with CRC screening recommendations. It is important to pay close attention to patient feedback surveys in order to improve healthcare delivery. [ABSTRACT FROM AUTHOR]

Introduction: The Affordable Care Act of 2010 mandated private health plans to fully cover the services recommended by the U.S. Preventive Services Task Force. In June 2016, the Task Force added computed tomography colonography to its list of recommended tests for colorectal cancer screening. This study evaluates the association among the updated recommendation, patient cost-sharing obligations, and the uptake of colorectal cancer screening through computed tomography colonography in the privately insured population.Methods: Using individual claims from the 2010-2018 IBM MarketScan Commercial Database, monthly screening computed tomography colonography utilization rates per 100,000 privately insured beneficiaries aged 50-64 years and the monthly proportions of these services delivered by in-network providers for which patients had to bear a portion of the procedure costs were calculated, and an interrupted time series analysis was performed. The study was conducted between January and May 2020.Results: Although the proportion of in-network procedures subject to patient cost sharing declined from 38.2% in 2010 to 10.2% in early 2016, the monthly utilization remained nearly constant. The announcement of the updated recommendation was associated with an immediate increase in the monthly screening computed tomography colonography utilization rate from 0.4 to 0.6 procedures per 100,000 individuals but with no change in the proportion of in-network procedures subject to patient cost sharing.Conclusions: In an environment of already largely eliminated patient cost sharing, the release of supportive evidence-based recommendations by a recognized credible body was associated with an immediate increase in computed tomography colonography use for colorectal cancer screening in the privately insured population. [ABSTRACT FROM AUTHOR]

The article focuses on colorectal cancer (CRC) apart from other forms of cancer as a serious population health issue. Topics include the succinct but profound answer is that it is the most preventable yet least prevented form of cancer, the CRC usually does not cause symptoms until the disease is well advanced, and the timely preventive screening is generally understood to be vitally important.

Introduction: This study examines individual- and practice-level predictors of screening modality among 1,484 Medicaid enrollees who initiated colorectal cancer screening (fecal immunochemical test/fecal occult blood tests or colonoscopy) within a year of turning age 50 years. Understanding screening modality patterns for patients and health systems can help optimize colorectal cancer screening initiatives that will lead to high screening completion rates.Methods: Multivariable logistic regression was conducted in 2019 to analyze Medicaid claims data (January 2013-June 2015) to explore predictors of colonoscopy screening (versus fecal testing).Results: Overall, 64% of enrollees received a colonoscopy and 36% received a fecal immunochemical test/fecal occult blood test. Male (OR=1.21, 95% CI=1.08, 1.37) compared with female enrollees and those with 4-6 (OR=1.57, 95% CI=1.15, 2.15), 7-10 (OR=2.23, 95% CI=1.64, 3.03), and ≥11 (OR=1.79, 95% CI=1.22, 2.65) primary care visits compared with 0-3 visits had higher odds of colonoscopy screening. Non-White, non-Hispanic enrollees (OR=0.71, 95% CI=0.58, 0.87) compared with White, non-Hispanics Whites had lower odds of colonoscopy screening. Practices with an endoscopy facility within their ZIP code (OR=1.50, 95% CI=1.08, 2.08) compared with practices without a nearby endoscopy facility had higher odds of colonoscopy screening.Conclusions: Among newly age-eligible Medicaid enrollees who received colorectal cancer screening, non-White, non-Hispanic individuals were less likely and male enrollees and those with ≥4 primary care visits were more likely to undergo colonoscopy versus fecal immunochemical test/fecal occult blood test. Colonoscopy also was the more common modality among adults whose primary care clinic had an endoscopy facility in the same ZIP code. Future research is needed to fully understand patient, provider, and practice preferences regarding screening modality. [ABSTRACT FROM AUTHOR]

Background: Mailed reminders to promote colorectal cancer (CRC) screening by fecal immunochemical testing (FIT) have been shown to be effective in the Medicaid population, in which screening is underused. However, little is known regarding the cost-effectiveness of these interventions, with or without an included FIT kit.Methods: The authors conducted a cost-effectiveness analysis of a randomized controlled trial that compared the effectiveness of a reminder + FIT intervention versus a reminder-only intervention in increasing FIT screening. The analysis compared the costs per person screened for CRC screening associated with the reminder + FIT versus the reminder-only alternative using a 1-year time horizon. Input data for a cohort of 35,000 unscreened North Carolina Medicaid enrollees ages 52 to 64 years were derived from the trial and microcosting. Inputs and outputs were estimated from 2 perspectives-the Medicaid/state perspective and the health clinic/facility perspective-using probabilistic sensitivity analysis to evaluate uncertainty.Results: The anticipated number of CRC screenings, including both FIT and screening colonoscopies, was higher for the reminder + FIT alternative (n = 8131; 23.2%) than for the reminder-only alternative (n = 5533; 15.8%). From the Medicaid/state perspective, the reminder + FIT alternative dominated the reminder-only alternative, with lower costs and higher screening rates. From the health clinic/facility perspective, the reminder + FIT versus the reminder-only alternative resulted in an incremental cost-effectiveness ratio of $116 per person screened.Conclusions: The reminder + FIT alternative was cost saving per additional Medicaid enrollee screened compared with the reminder-only alternative from the Medicaid/state perspective and likely cost-effective from the health clinic/facility perspective. The results also demonstrate that health departments and state Medicaid programs can efficiently mail FIT kits to large numbers of Medicaid enrollees to increase CRC screening completion. [ABSTRACT FROM AUTHOR]

Background: Promoting uptake of evidence-based innovations in healthcare systems requires attention to how innovations are adapted to enhance their fit with a given setting. Little is known about real-world variation in how programs are delivered over time and across multiple populations and contexts, and what motivates adaptations.Methods: As part of the BeneFIT study of mailed fecal immunochemical tests (FIT) to increase colorectal cancer screening, we interviewed 9 leaders from two participating Medicaid/Medicare health insurance plans to examine adaptations to their health plan-initiated mailed FIT outreach programs in the second year of implementation. We applied an adaptation and modification model developed by Stirman and colleagues to document content and context modifications made to the two programs.Results: Both health plans made substantial changes to their programs in the second year; adaptations differed substantially across health plans. In Health Plan Oregon, adaptations generally targeted health centers and member populations, most content adaptations involved tailoring program components, and the program was expanded to four additional health centers. In contrast, Health Plan Washington's second-year content adaptations were primarily at the level of members, and generally involved adding program components. Moreover, Health Plan Washington undertook large-scale context adaptations to the setting where the program was led (local vs. national), the personnel who administered the program (vendor and staffing), and the population selected for outreach (limiting outreach to dual-eligible members).Conclusions: Both programs implemented a variety of adaptations that reflected the values and incentives of the broader health plan contexts. Financial incentives for screening allowed Health Plan Oregon to expand but led Health Plan Washington to offer more targeted outreach to a subset of eligible enrollees. The breadth of changes made by each health system reflects the necessity of evaluating programs in context and adjusting to specific challenges as they are identified. Further research is needed to understand the effects of these types of adaptations on program efficiency and enrollee and health system outcomes. [ABSTRACT FROM AUTHOR]

Uptake of colorectal cancer screening remains suboptimal. Mailed fecal immunochemical testing (FIT) offers promise for increasing screening rates, but optimal strategies for implementation have not been well synthesized. In June 2019, the Centers for Disease Control and Prevention convened a meeting of subject matter experts and stakeholders to answer key questions regarding mailed FIT implementation in the United States. Points of agreement included: 1) primers, such as texts, telephone calls, and printed mailings before mailed FIT, appear to contribute to effectiveness; 2) invitation letters should be brief and easy to read, and the signatory should be tailored based on setting; 3) instructions for FIT completion should be simple and address challenges that may lead to failed laboratory processing, such as notation of collection date; 4) reminders delivered to initial noncompleters should be used to increase the FIT return rate; 5) data infrastructure should identify eligible patients and track each step in the outreach process, from primer delivery through abnormal FIT follow-up; 6) protocols and procedures such as navigation should be in place to promote colonoscopy after abnormal FIT; 7) a high-quality, 1-sample FIT should be used; 8) sustainability requires a program champion and organizational support for the work, including sufficient funding and external policies (such as quality reporting requirements) to drive commitment to program investment; and 9) the cost effectiveness of mailed FIT has been established. Participants concluded that mailed FIT is an effective and efficient strategy with great potential for increasing colorectal cancer screening in diverse health care settings if more widely implemented. [ABSTRACT FROM AUTHOR]

Background: Cancer screening is a complex process encompassing risk assessment, the initial screening examination, diagnostic evaluation, and treatment of cancer precursors or early cancers. Metrics that enable comparisons across different screening targets are needed. We present population-based screening metrics for breast, cervical, and colorectal cancers for nine sites participating in the Population-based Research Optimizing Screening through Personalized Regimens consortium.Methods: We describe how selected metrics map to a trans-organ conceptual model of the screening process. For each cancer type, we calculated calendar year 2013 metrics for the screen-eligible target population (breast: ages 40-74 years; cervical: ages 21-64 years; colorectal: ages 50-75 years). Metrics for screening participation, timely diagnostic evaluation, and diagnosed cancers in the screened and total populations are presented for the total eligible population and stratified by age group and cancer type.Results: The overall screening-eligible populations in 2013 were 305 568 participants for breast, 3 160 128 for cervical, and 2 363 922 for colorectal cancer screening. Being up-to-date for testing was common for all three cancer types: breast (63.5%), cervical (84.6%), and colorectal (77.5%). The percentage of abnormal screens ranged from 10.7% for breast, 4.4% for cervical, and 4.5% for colorectal cancer screening. Abnormal breast screens were followed up diagnostically in almost all (96.8%) cases, and cervical and colorectal were similar (76.2% and 76.3%, respectively). Cancer rates per 1000 screens were 5.66, 0.17, and 1.46 for breast, cervical, and colorectal cancer, respectively.Conclusions: Comprehensive assessment of metrics by the Population-based Research Optimizing Screening through Personalized Regimens consortium enabled systematic identification of screening process steps in need of improvement. We encourage widespread use of common metrics to allow interventions to be tested across cancer types and health-care settings. [ABSTRACT FROM AUTHOR]

Description: The purpose of this guidance statement is to guide clinicians on colorectal cancer screening in average-risk adults.Methods: This guidance statement is derived from a critical appraisal of guidelines on screening for colorectal cancer in average-risk adults and the evidence presented in these guidelines. National guidelines published in English between 1 June 2014 and 28 May 2018 in the National Guideline Clearinghouse or Guidelines International Network library were included. The authors also included 3 guidelines commonly used in clinical practice. Web sites were searched for guideline updates in December 2018. The AGREE II (Appraisal of Guidelines for Research and Evaluation II) instrument was used to evaluate the quality of guidelines.Target Audience and Patient Population: The target audience is all clinicians, and the target patient population is adults at average risk for colorectal cancer.Guidance Statement1: Clinicians should screen for colorectal cancer in average-risk adults between the ages of 50 and 75 years.Guidance Statement2: Clinicians should select the colorectal cancer screening test with the patient on the basis of a discussion of benefits, harms, costs, availability, frequency, and patient preferences. Suggested screening tests and intervals are fecal immunochemical testing or high-sensitivity guaiac-based fecal occult blood testing every 2 years, colonoscopy every 10 years, or flexible sigmoidoscopy every 10 years plus fecal immunochemical testing every 2 years.Guidance Statement3: Clinicians should discontinue screening for colorectal cancer in average-risk adults older than 75 years or in adults with a life expectancy of 10 years or less. [ABSTRACT FROM AUTHOR]

Mailed outreach promoting colorectal cancer (CRC) screening with a stool blood test kit may increase participation, but magnitude and consistency of benefit of this intervention strategy is uncertain. Our aim was to conduct a systematic review and meta-analysis of randomized controlled trials (RCTs) comparing mailed outreach offering stool tests to usual care, clinic-based screening offers on CRC screening uptake in the USA. We performed a systematic literature search of five databases for RCTs of mailed outreach from January 1980 through June 2017. Primary outcome was screening completion, summarized using random-effects meta-analysis as pooled differences in proportion completing the screening and relative risk of achieving screening compared to control. Subgroup analyses by test type offered-fecal immunochemical test (FIT) or guaiac fecal occult blood test (gFOBT), the presence of telephone reminders, and the presence of predominant underserved/minority population within study were performed. Quality of evidence was evaluated using the GRADE framework. Seven RCTs which enrolled 12,501 subjects were included (n = 5703 assigned mailed outreach and n = 6798 usual care). Mailed outreach resulted in a 28% absolute (95% CI 25-30%; I2 = 47%) and a 2.8-fold relative (RR 2.65, 95% CI 2.03-3.45; I2 = 92%) increase in screening completion compared to usual care, with a number needed to invite estimated to be 3.6. Similar outcomes were observed across subgroups. Overall body of evidence was at moderate quality. Mailed outreach offering a gFOBT or FIT is associated with a large and consistent increase in CRC screening completion and should be considered for more widespread implementation for improving screening rates nationwide. [ABSTRACT FROM AUTHOR]

Background: Average-risk women aged 50-59 years have a lower incidence and mortality of colorectal cancer relative to age-matched men, calling into question the benefit of screening colonoscopy in this age group.Aims: We aimed to determine whether FOBT is an effective initial screening test in 50-59-year-old women.Methods: We conducted a cross-sectional study using a computerized endoscopic report generator. We identified 320,906 individuals who had average-risk screening colonoscopy and 32,369 who had colonoscopy for positive FOBT. The primary outcome was the positive predictive value (PPV) of FOBT for large polyp(s) greater than 9 mm, as a surrogate for advanced neoplasia.Results: Among patients aged 50-59 years undergoing screening colonoscopy, men were more likely than women to have large polyps (6.3 vs 4.2%, p < 0.0001). Black women undergoing screening colonoscopy had higher rates of large polyps compared to non-Black women. The PPV in FOBT-positive men aged 50-54 (11.5%) and 55-59 (14.4%) was higher than in women aged 50-54 (6.1%) and 55-59 (5.4%). Despite this lower PPV, women aged 50-54 with a positive FOBT had a similar rate of large polyps as 50-54-year-old men undergoing screening colonoscopy (6.1 vs 6.3%, p = 0.626).Conclusions: CRC screening with FOBT identifies 50-59-year-old men and women with a higher risk of large polyps. Since younger women have a lower risk of large polyps than men, screening with FOBT in 50-59-year-old non-Black women could be an effective screening strategy, with outcomes similar to the use of screening colonoscopy in 50-59-year-old men. [ABSTRACT FROM AUTHOR]

Background: Colorectal cancer (CRC) screening is effective but underused. Screening rates are lower among Medicaid beneficiaries versus other insured populations. No studies have examined mailed fecal immunochemical testing (FIT)-based outreach programs for Medicaid beneficiaries.Methods: In a patient-level randomized controlled trial, a mailed CRC screening reminder plus FIT, sent from an urban health department to Medicaid beneficiaries, was compared with the same reminder without FIT. The reminder group could request FIT. Completed FIT kits were processed by the health department laboratory. Respondents were notified of normal results by mail. Abnormal results were given via phone by a patient navigator who provided counselling and assistance with follow-up care. The primary outcome was FIT return.Results: In all, 2144 beneficiaries at average CRC risk were identified, and there was no evidence of screening with Medicaid claims data. To the reminder+FIT group, 1071 were randomized, and 1073 were randomized to the reminder group; 307 (28.7%) in the reminder+FIT group and 347 (32.3%) in the reminder group were unreachable or ineligible (previous screening). The FIT return rate was significantly higher in the reminder+FIT group than the reminder group (21.1% vs 12.3%; difference, 8.8%; 95% confidence interval, 3.7%-13.9%; P < .01). Eighteen individuals (7.2%) who completed FIT tests had abnormal results, and 15 were eligible for follow-up colonoscopy; 66.7% (n = 10) completed follow-up colonoscopy.Conclusions: A health department-based, mailed FIT program targeting Medicaid beneficiaries was feasible. Including a FIT kit resulted in greater screening completion than a reminder letter alone. Further research is needed to understand the comparative cost-effectiveness of these interventions. [ABSTRACT FROM AUTHOR]

Introduction: Screening for colorectal cancer in average-risk adults is recommended beginning at age 50 years and continuing until age 75 years. This study was conducted to provide evidence for the effectiveness of an American Cancer Society grant program promoting colorectal cancer screening by implementing evidence-based interventions proven to increase screening rates.Methods: Analysis compared colorectal cancer screening rates in 77 grant-funded federally qualified health centers between 2013 and 2015 to those of a sample of 77 nonfunded federally qualified health centers selected using a genetic matching technique. The Uniform Data System from 2013 to 2015 provided data used in the analysis performed in 2016.Results: Funded grantees differed significantly from nongrantees on several indicators at baseline. Genetic matching resulted in good-quality matched samples. Both matched samples increased colorectal cancer screening rates over time. Grantees increased their colorectal cancer screening rates significantly more than nongrantees, especially between 2013 and 2014, where funded federally qualified health centers increased by 9% and nonfunded federally qualified health centers increased by 3%. Across the 3 years, increases were 12% and 9%, respectively.Conclusions: The findings suggest grant funding was effective in promoting improvements in colorectal cancer screening rates in funded federally qualified health centers, and these improvements exceed those of nonfunded federally qualified health centers. Funding that results in targeted, intensive efforts supported by technical assistance and accountability for data and reporting, can result in improved system policies and practices that, in turn, can increase screening rates among uninsured and underserved populations. [ABSTRACT FROM AUTHOR]

Background: Interventions to improve fecal testing for colorectal cancer (CRC) exist, but are not yet routine practice. We conducted this systematic review to determine how implementation strategies and contextual factors influenced the uptake of interventions to increase Fecal Immunochemical Tests (FIT) and Fecal Occult Blood Testing (FOBT) for CRC in rural and low-income populations in the United States.Methods: We searched Medline and the Cochrane Library from January 1998 through July 2016, and Scopus and clinicaltrials.gov through March 2015, for original articles of interventions to increase fecal testing for CRC. Two reviewers independently screened abstracts, reviewed full-text articles, extracted data and performed quality assessments. A qualitative synthesis described the relationship between changes in fecal testing rates for CRC, intervention components, implementation strategies, and contextual factors. A technical expert panel of primary care professionals, health system leaders, and academicians guided this work.Results: Of 4218 citations initially identified, 27 unique studies reported in 29 publications met inclusion criteria. Studies were conducted in primary care (n = 20, 74.1%), community (n = 5, 18.5%), or both (n = 2, 7.4%) settings. All studies (n = 27, 100.0%) described multicomponent interventions. In clinic based studies, components that occurred most frequently among the highly effective/effective study arms were provision of kits by direct mail, use of a pre-addressed stamped envelope, client reminders, and provider ordered in-clinic distribution. Interventions were delivered by clinic staff/community members (n = 10, 37.0%), research staff (n = 6, 22.2%), both (n = 10, 37.0%), or it was unclear (n = 1, 3.7%). Over half of the studies lacked information on training or monitoring intervention fidelity (n = 15, 55.6%).Conclusions: Studies to improve FIT/FOBT in rural and low-income populations utilized multicomponent interventions. The provision of kits through the mail, use of pre-addressed stamped envelopes, client reminders and in-clinic distribution appeared most frequently in the highly effective/effective clinic-based study arms. Few studies described contextual factors or implementation strategies. More robust application of guidelines to support reporting on methods to select, adapt and implement interventions can help end users determine not just which interventions work to improve CRC screening, but which interventions would work best in their setting given specific patient populations, clinical settings, and community characteristics.Trial Registration: In accordance with PRISMA guidelines, our systematic review protocol was registered with PROSPERO, the international prospective register of systematic reviews, on April 16, 2015 (registration number CRD42015019557 ). [ABSTRACT FROM AUTHOR]

Objectives Population-based evidence regarding impact of cancer screenings and cancer rates in Missouri is lacking. This study examined whether screenings of breast cancer, cervical cancer, and colorectal cancer impact early-stage cancer incidence and mortality in Missouri. Study design This is an ecological study based on county-specific estimates of selected cancer screening prevalence and early-stage cancer incidence and cancer mortality. Methods County-specific prevalence of clinical breast examination, mammography, Pap test, sigmoidoscopy or colonoscopy, and fecal occult blood test (FOBT) were generated from Missouri County-Level Study (2003, 2007, and 2011). County-specific crude incidence and mortality were calculated (2004-2013). Pearson's correlation and Poisson regression were used to test association between cancer rate and screening prevalence. Covariates included county-level mean age, percentage of whites, percentage with low income, percentage with less than high school education high school, percentage with no insurance, and percentage having difficulties accessing care. Results In the adjusted model, 'ever had Pap test' was significantly associated with an increase of 8% in early-stage cervical cancer incidence. Having clinical breast examination or Pap test in the past was also associated with decreases in mortality by 3% and 4%, respectively, although the association was not significant for Pap test. In addition, having mammography was statistically significantly associated with early-stage breast cancer incidence, and having FOBT or sigmoidoscopy or colonoscopy was associated with decreased colorectal cancer mortality; however, magnitude for these associations was only around 1%. Conclusions This study provides ecological evidence of the effectiveness of screening services in predicting early stage cancer incidence and in reducing mortality across Missouri counties. Further incentive to promote these screenings in Missouri is needed. [ABSTRACT FROM AUTHOR]

The USPS Task Force recommends screening for colorectal cancer (CRC) in adults aged 45–75. Screening rates are low in underserved populations. We conducted a systematic review of interventions to increase CRC screening adherence in low-income settings in US. We included randomized control trials of CRC screening interventions conducted in low-income settings in the US. Outcome was CRC screening adherence. Random-effects meta-analysis of relative risks was conducted for the effectiveness of CRC screening interventions. We identified 46 studies that met inclusion criteria. Interventions were grouped into four categories: mailed outreach, patient navigation, patient education, and types of reminders. Mailed outreach with enclosed fecal immunohistochemical test (FIT) (RR 2.20, 95% CI 1.74, 2.78), guaiac based fecal occult blood test (gFOBT) (RR 4.34, 95% CI 1.29, 14.67), and without FIT/gFOBT (RR 1.80, 95% CI 1.15, 2.82) all significantly increased CRC screening, as did non-individualized education (RR 1.44, 95% CI 1.07, 1.94) and patient navigation (RR 1.62, 95% CI 1.29, 2.02). Mailed outreach with an incentive (RR 0.97, 95% CI 0.81, 1.16) and individualized education (RR 1.07, 95% CI 0.83, 1.38) did not significantly improve screening adherence. Telephone reminders are slightly more effective than reminder letters (RR 1.16, 95% CI 1.02, 1.33), but there is no difference between personal or automated phone calls (RR 1.17, 95% CI 0.74, 1.84). Mailed outreach and patient navigation are the most effective strategies to improve colorectal cancer screening in low-income populations. There was significant heterogeneity between studies, likely due to differences in intervention design, screening tests, and follow-up. • Mailed outreach with or without screening kits significantly improves CRC screening adherence. • Patient navigation or education is an effective strategy overall but varies by study. • General interventions may be as effective as more tailored or personalized interventions. • Different choices of patient reminders are equally effective. [ABSTRACT FROM AUTHOR]

Purpose Colorectal cancer (CRC) screening saves patient suffering and health system expenses if the pathology is found in its early stages. Utilizing rapid process improvement cycles, the purpose of this paper is to improve the rate of CRC screening in a rural community in the USA.Design/methodology/approach Data were gathered from the authors’ electronic medical record. Non provider staff were trained to do the majority of the work utilizing population health, clinic visit checklists, and standard work. The two tests used were colonoscopy and fecal immunochemical test testing.Findings Dramatic improvement in the rates of colorectal screening were achieved. The base rate of documented CRC screening was 22 percent, with the rate two years later being 62.7 percent.Originality/value This work is of interest to those working in primary care, gastroenterology, general surgery, or if interested in designing standard work. [ABSTRACT FROM AUTHOR]

Background: Population outreach strategies are increasingly used to improve colorectal cancer (CRC) screening. The influence of primary care on cancer screening in this context is unknown.Objective: To assess associations between primary care provider (PCP) visits and receipt of CRC screening and colonoscopy after a positive fecal immunochemical (FIT) or fecal occult blood test (FOBT).Design: Population-based cohort study.Participants: A total of 968,072 patients ages 50-74 years who were not up to date with CRC screening in 2011 in four integrated healthcare systems (three with screening outreach programs using FIT kits) in the Population-Based Research Optimizing Screening through Personalized Regimens (PROSPR) consortium.Measures: Demographic, clinical, PCP visit, and CRC screening data were obtained from electronic health records and administrative databases. We examined associations between PCP visits in 2011 and receipt of FIT/FOBT, screening colonoscopy, or flexible sigmoidoscopy (CRC screening) in 2012 and follow-up colonoscopy within 3 months of a positive FIT/FOBT in 2012. We used multivariable logistic regression and propensity score models to adjust for confounding.Results: Fifty-eight percent of eligible patients completed a CRC screening test in 2012, most by FIT. Those with a greater number of PCP visits had higher rates of CRC screening at all sites. Patients with ≥1 PCP visit had nearly twice the adjusted-odds of CRC screening (OR = 1.88, 95 % CI: 1.86-1.89). Overall, 79.6 % of patients with a positive FIT/FOBT completed colonoscopy within 3 months. Patients with ≥1 PCP visit had 30 % higher adjusted odds of completing colonoscopy after positive FIT/FOBT (OR = 1.30; 95 % CI: 1.22-1.40).Conclusions: Patients with a greater number of PCP visits had higher rates of both incident CRC screening and colonoscopy after positive FIT/FOBT, even in health systems with active population health outreach programs. In this era of virtual care and population outreach, primary care visits remain an important mechanism for engaging patients in cancer screening. [ABSTRACT FROM AUTHOR]

Assessments of colorectal cancer (CRC) screening rates typically rely on self-reported screening data, which are often incongruent with medical records. We used multilevel models to examine health-related, socio-demographic and psychological predictors of incongruent self-reports for CRC screening among Medicare-insured African Americans (N = 3,740). Results indicated that living alone decreased, and income increased, the odds of congruently self-reporting endoscopic CRC screening. Being male and having greater number of comorbidities decreased, and having less than a high school education increased, the odds of congruently self-reported fecal occult blood tests. Living alone, age and income had the most robust effects across classifications into one of four mutually exclusive categories defined by screening status (screened/unscreened) and congruence of self-reports. The results underscore the clinical importance of gathering socio-demographic data via patient interviews, and the relevance of these data for judging the veracity of self-reported CRC screenings behaviors. [ABSTRACT FROM AUTHOR]

Purpose: Fecal occult blood testing (FOBT) is a pragmatic screening option for many community health centers (CHCs), but FOBT screening programs will not reduce mortality if patients with positive results do not undergo diagnostic colonoscopy (DC). This study was conducted to investigate DC completion among CHC patients.Methods: This retrospective cohort study used data from three CHCs in the Midwest and Southwest. The primary study outcome was DC completion within 6 months of positive FOBT among adults age 50-75. Patient data was collected using automated electronic queries. Manual chart reviews were conducted if queries produced no evidence of DC. Poisson regression models described adjusted relative risks (RRs) of DC completion.Results: The study included 308 patients; 63.3 % were female, 48.7 % were Spanish speakers and 35.7 % were uninsured. Based on combined query and chart review findings, 51.5 % completed DC. Spanish speakers were more likely than English speakers to complete DC [RR 1.19; 95 % confidence interval (CI) 1.04-1.36; P = 0.009], and DC completion was lower among patients with 0 visits than those with 1-2 visits (RR 2.81; 95% CI 1.83-4.33; P < 0.001) or ≥3 visits (RR 3.06; 95% CI 1.57-5.95; P = 0.001).Conclusions: DC completion was low overall, which raises concerns about whether FOBT can reduce CRC mortality in practice. Further research is needed to understand whether CHC navigator programs can achieve very high DC rates. If organizations use FOBT as their primary CRC screening approach and a substantial number of patients receive positive results, both screening rates and DC rates should be measured. [ABSTRACT FROM AUTHOR]

Importance: The US Preventive Services Task Force (USPSTF) is updating its 2008 colorectal cancer (CRC) screening recommendations.Objective: To inform the USPSTF by modeling the benefits, burden, and harms of CRC screening strategies; estimating the optimal ages to begin and end screening; and identifying a set of model-recommendable strategies that provide similar life-years gained (LYG) and a comparable balance between LYG and screening burden.Design, Setting, and Participants: Comparative modeling with 3 microsimulation models of a hypothetical cohort of previously unscreened US 40-year-olds with no prior CRC diagnosis.Exposures: Screening with sensitive guaiac-based fecal occult blood testing, fecal immunochemical testing (FIT), multitarget stool DNA testing, flexible sigmoidoscopy with or without stool testing, computed tomographic colonography (CTC), or colonoscopy starting at age 45, 50, or 55 years and ending at age 75, 80, or 85 years. Screening intervals varied by modality. Full adherence for all strategies was assumed.Main Outcomes and Measures: Life-years gained compared with no screening (benefit), lifetime number of colonoscopies required (burden), lifetime number of colonoscopy complications (harms), and ratios of incremental burden and benefit (efficiency ratios) per 1000 40-year-olds.Results: The screening strategies provided LYG in the range of 152 to 313 per 1000 40-year-olds. Lifetime colonoscopy burden per 1000 persons ranged from fewer than 900 (FIT every 3 years from ages 55-75 years) to more than 7500 (colonoscopy screening every 5 years from ages 45-85 years). Harm from screening was at most 23 complications per 1000 persons screened. Strategies with screening beginning at age 50 years generally provided more LYG as well as more additional LYG per additional colonoscopy than strategies with screening beginning at age 55 years. There were limited empirical data to support a start age of 45 years. For persons adequately screened up to age 75 years, additional screening yielded small increases in LYG relative to the increase in colonoscopy burden. With screening from ages 50 to 75 years, 4 strategies yielded a comparable balance of screening burden and similar LYG (median LYG per 1000 across the models): colonoscopy every 10 years (270 LYG); sigmoidoscopy every 10 years with annual FIT (256 LYG); CTC every 5 years (248 LYG); and annual FIT (244 LYG).Conclusions and Relevance: In this microsimulation modeling study of a previously unscreened population undergoing CRC screening that assumed 100% adherence, the strategies of colonoscopy every 10 years, annual FIT, sigmoidoscopy every 10 years with annual FIT, and CTC every 5 years performed from ages 50 through 75 years provided similar LYG and a comparable balance of benefit and screening burden. [ABSTRACT FROM AUTHOR]

Now that cancer has surpassed heart disease as the top cause of death for Hispanics in the United States, it is even more critical to focus on early detection of cancer in this population. We report the results of a theory-driven education-plus-navigation pilot intervention delivered by bilingual, bicultural community health workers (CHWs) with the goal of increasing cancer screening rates and knowledge among low-income Latinas. CHWs enrolled 691 eligible women, ages 18 to 75 years, considered rarely or never screened for breast, cervical, and colorectal cancer. Eligible women were scheduled for an education session and offered health care navigation support with appointment scheduling and reminder/follow-up calls. CHWs provided education to 535 (77%) eligible women, and arranged mammograms, Pap tests, or stool blood tests for 174 (25%) participants, with another 94 (14%) placed on a waiting list at a local health center. Statistically significant positive changes on knowledge of screening guidelines for breast, cervical, and colorectal cancer, and beliefs/attitudes regarding early detection were observed from pre- to posttest among eligible women who attended an educational session. Results highlight the effectiveness of CHW-directed interventions in recruiting individuals for programs, educating them, and influencing cancer knowledge and screening behavior. [ABSTRACT FROM AUTHOR]

Background: The current study was conducted to determine the effect of continuing a centralized fecal occult blood test (FOBT) mailed program on screening adherence.Methods: A patient-level randomized controlled trial was conducted in 21 patient-centered medical home primary care clinics between January 2010 and November 2012. A total of 2208 patients ranging in age from 52 to 75 years in a substudy of the Systems of Support to Increase Colon Cancer Screening and Follow-Up (SOS) trial were randomized at year 3 to continued automated interventions (Continued group), which included mailed information regarding colorectal cancer (CRC) screening choices, and were mailed stool kit tests or to a group in which interventions were stopped (Stopped group). The main outcomes and measures were the completion of CRC screening in year 3 and by subgroup characteristics, respectively.Results: Adherence to CRC screening in year 3 was found to be significantly higher in patients in the Continued group compared with those in the Stopped group (53.3% vs 37.3%; adjusted net difference, 15.6% [P<.001]). This difference was entirely due to greater completion of FOBT (adjusted net difference, 18.0% [P<.001]). Year 3 CRC screening rates were highest in patients in the Continued group completing FOBT in both years 1 and 2 (77.2%), followed by patients completing only 1 FOBT in 1 of the 2 years (44.6%), with low rates of CRC testing reported among patients not completing any FOBT within the first 2 years (18.1%).Conclusions: A centralized mailed FOBT CRC screening program continued to be more effective than patient-centered medical home usual-care interventions, but only for those patients who had previously completed FOBT testing. Research is needed regarding how to engage patients not completing CRC testing after being mailed at least 2 rounds of FOBT tests. Cancer 2016;122:312-321. © 2015 American Cancer Society. [ABSTRACT FROM AUTHOR]

Objectives. We assessed the protocols and system processes for colorectal cancer (CRC) screening at federally qualified health centers (FQHCs) in 4 midwestern states. Methods. We identified 49 FQHCs in 4 states. In January 2013, we mailed their medical directors a 49-item questionnaire about policies on CRC screening, use of electronic medical records, types of CRC screening recommended, clinic tracking systems, referrals for colonoscopy, and barriers to providing CRC. Results. Forty-four questionnaires (90%) were returned. Thirty-three of the respondents (75%) estimated the proportion of their patients up-to-date with CRC screening, with a mean of 35%. One major barrier to screening was inability to provide colonoscopy for patients with a positive fecal occult blood test (59%). The correlation of system strategies and estimated percentage of patients up-to-date with CRC screening was 0.43 (P = .01). Conclusions. CRC system strategies were associated with higher CRC screening rates. Implementing system strategies for CRC screening takes time and effort and is important to maintain, to help prevent, or to cure many cases of CRC, the second leading cause of cancer in the United States. [ABSTRACT FROM AUTHOR]

The article focuses on the use of fecal immunochemical testing (FIT) in colorectal cancer (CRC) screening in the U.S. Topics include the release of an examination of evidence by the U.S. Multi-Society Task Force on the use of FIT for CRC screening in average-risk populations, available CRC screening test in the U.S., and provision under the Patient Protection and Affordable Care Act on preventive services endorsed by the U.S. Preventive Services Task Force including CRC screening.

BACKGROUND The objectives of this study were to describe, examine, and compare prevalence estimates of colorectal cancer (CRC) screening practices and to determine whether disparities exist for American Indians/Alaska Natives (AIANs) and blacks compared with whites. METHODS Behavioral Risk Factor Surveillance System (2001-2010) data from respondents aged ≥50 years (n = 356,073) were used. The primary outcome was self-reported CRC screening according to US Preventive Services Task Force guidelines for endoscopy (colonoscopy or sigmoidoscopy), fecal occult blood test (FOBT), or mixed screening (endoscopy or FOBT). RESULTS From 2001 to 2010, endoscopy screening increased in the AIAN population by 44.8% ( P < .001) compared with black respondents (51.7%) and white respondents (26.5%). AIANs were less likely to report endoscopy screening (45%) compared with both blacks (56%) and whites (55%). For mixed CRC screenings, AIAN rates increased by 34.5%, compared with 29.7% for blacks and 15% for whites. In 2010, AIANs (51%) had the lowest prevalence of mixed CRC screening compared with blacks (61%) and whites (60%; P < .001). Factors that enabled health care attenuated the lowered likelihood of CRC screenings, but disparities remained for AIAN CRC screening. In contrast, once enabling factors were controlled, the odds ratios of CRC screening among blacks were higher compared with whites. CONCLUSIONS Between 2001 and 2010, AIANs had the lowest CRC screening rates in the United States compared with blacks and whites, presenting a CRC disparity, as rigorously defined. The current findings indicate that, although considerable progress has been made to increase CRC screening for blacks and whites, progress for AIANs continues to lag behind in the first decade of 21st century. Cancer 2014;120:3192-3299. © 2014 American Cancer Society. [ABSTRACT FROM AUTHOR]

GOVERNMENT, LAW, AND PUBLIC HEALTH PRACTICE Policies to Achieve Health Equity Navigating the Murky Waters of Colorectal Cancer Screening and Health Reform I Beverly B. Green, MD, MPH, Gloria D. Coronado, PhD, Jennifer E, Devoe, MD, DPhil, and James Allison, MD The Affordable Care Act (ACA) mandates that both Medicaid and insurance plans cover life-saving preventive services recommended by the US Preventive Services Task Force, including colorectal cancer (CRC) screening and choice between colonoscopy, flexible sigmoidoscopy, and fecal occult blood testing (FOBT). People who choose FOBT or sigmoidoscopy as their initial test could face high, unexpected, out-of-pocket costs because the mandate does not cover needed follow-up colonoscopies after positive tests. Some people will have no coverage for any CRC screening because of lack of state participation in the ACA or because they do not qualify (e.g., immigrant workers). Existing disparities in CRC screening and mortality will worsen if policies are not corrected to fully cover both initial and follow-up testing. [ABSTRACT FROM AUTHOR]

Background Delayed diagnosis of cancer can lead to patient harm, and strategies are needed to proactively and efficiently detect such delays in care. We aimed to develop and evaluate 'trigger' algorithms to electronically flag medical records of patients with potential delays in prostate and colorectal cancer (CRC) diagnosis. Methods We mined retrospective data from two large integrated health systems with comprehensive electronic health records (EHR) to iteratively develop triggers. Data mining algorithms identified all patient records with specific demographics and a lack of appropriate and timely follow-up actions on four diagnostic clues that were newly documented in the EHR: abnormal prostate-specific antigen (PSA), positive faecal occult blood test (FOBT), iron-deficiency anaemia (IDA), and haematochezia. Triggers subsequently excluded patients not needing follow-up (eg, terminal illness) or who had already received appropriate and timely care. Each of the four final triggers was applied to a test cohort, and chart reviews of randomly selected records identified by the triggers were used to calculate positive predictive values (PPV). Results The PSA trigger was applied to records of 292 587 patients seen between 1 January 2009 and 31 December 2009, and the CRC triggers were applied to 291 773 patients seen between 1 March 2009 and 28 February 2010. Overall, 1564 trigger positive patients were identified (426 PSA, 355 FOBT, 610 IDA and 173 haematochezia). Record reviews revealed PPVs of 70.2%, 66.7%, 67.5%, and 58.3% for the PSA, FOBT, IDA and haematochezia triggers, respectively. Use of all four triggers at the study sites could detect an estimated 1048 instances of delayed or missed follow-up of abnormal findings annually and 47 high-grade cancers. Conclusions EHR-based triggers can be used successfully to flag patient records lacking follow-up of abnormal clinical findings suspicious for cancer. [ABSTRACT FROM AUTHOR]

One of the largest disparities in cancer mortality in the United States occurs with colorectal cancer (CRC). The objectives of this multilevel two-arm intervention trial were to compare the efficacy of two interventions to promote CRC screening (CRCS) with fecal immunochemical test (FIT) and examine sociodemographic and psychosocial predictors of FIT screening. Individuals ages 50-75 (n = 326) who were not up-to-date with CRCS, could understand English or Spanish, and were at average CRC risk were recruited from two federally qualified health centers (FQHCs) in Florida. Prior to intervention, CRCS rates in the FQHCs were 27.1% and 32.9%, respectively. Study enrollment occurred April 2018-November 2019. System-level intervention components included leveraging electronic medical record (EMR) systems and delivering patient reminders. Participants were randomized to C-CARES (education+FIT) or C-CARES Plus (C-CARES+personalized coaching [for those not completing FIT within 90 days]). Primary outcome was completed FIT returned <1 year. Primary outcome analyses were performed using logistic regression. 225 participants completed FIT (69.0% [95% CI: 64.0-74.0%]), with no significant difference in FIT uptake by intervention arm (67.3% C-CARES Plus vs. 70.8% C-CARES; p = .49). FIT uptake was significantly higher among patients who received intervention materials in Spanish (77.2%) compared to those who received materials in English (63.2%, p < .01). The personalized coaching in the C-CARES Plus arm did not appear to provide added benefit beyond the C-CARES intervention. Multilevel approaches that include EMR prompts, reminders, FIT access, and provision of low-literacy, language-concordant education can support efforts to improved community clinics' CRCS rates. Future efforts should focus on repeat FIT screening. Trial registration: The trial was registered at ClinicalTrials.gov (NCT03906110). [ABSTRACT FROM AUTHOR]

Background: Strong evidence exists that screening with fecal occult blood testing (FOBT), sigmoidoscopy, or colonoscopy reduces the number of deaths from colorectal cancer (CRC). The percentage of the population up-to-date with recommended CRC screening increased from 54% in 2002 to 65% in 2010, primarily through increased use of colonoscopy. Methods: Data from the 2012 Behavioral Risk Factor Surveillance System survey were analyzed to estimate percentages of adults aged 50-75 years who reported CRC screening participation consistent with United States Preventive Services Task Force recommendations. Results: In 2012, 65.1% of U.S. adults were up-to-date with CRC screening, and 27.7% had never been screened. The proportion of respondents who had never been screened was greater among those without insurance (55.0%) and without a regular care provider (61.0%) than among those with health insurance (24.0%) and a regular care provider (23.5%). Colonoscopy was the most commonly used screening test (61.7%), followed by FOBT (10.4%). Colonoscopy was used by more than 53% of the population in every state. The percentages of blacks and whites up-to-date with CRC screening were equivalent. Compared with whites, a higher percentage of blacks across all income and education levels used FOBT. Conclusions: Many age-eligible adults did not use any type of CRC screening test as recommended. Organized, population-based approaches might increase CRC screening among those who have never been screened. Promoting both FOBT and colonoscopy as viable screening test options might increase CRC screening rates and reduce health disparities. [ABSTRACT FROM AUTHOR]

The article discusses pathobiology, screening, and diagnosis of colorectal cancer and lists its risk factors. It presents clinical signs and symptoms of colorectal cancer which emerge after the cancer is already advanced. It states that CT colonography helps in colorectal cancer diagnosis. It also discusses how CT colonography findings are reported and CT colonography scanning parameters. It mentions how to identify indications and contraindications for computed tomography (CT) colonography.

Abstract: Objective: To examine the independent associations between multiple health status indicators and breast and colorectal cancer screening (CRCS) in a national US sample. Study design and setting: Analysis of cross-sectional data from the 2005 National Health Interview Survey (NHIS) involved 5115 men and 7100 women aged 50 years and older. Measures: Health status indicators included: self-reported perceived health status, number of chronic conditions, and functional limitation due to a chronic condition. Individuals were considered adherent to CRCS guidelines if they reported having a home-based fecal occult blood test in the past year or endoscopy in the past 10 years. Women were adherent to breast cancer screening guidelines if they reported having a mammogram in the previous 2 years. Statistical analyses were conducted using SUDAAN software to account for the complex sampling of the NHIS survey. Logistic regression was used to examine associations between each of the health status indicators and screening adherence for CRCS and mammography and to calculate estimated screening rates. Results: The three health status indicators were independently and differentially associated with screening adherence. Poor perceived health was associated with lower mammography among women, whereas a greater number of chronic conditions were consistently associated with greater screening. In adjusted analyses, functional limitation was only significantly associated with greater CRCS among women. Conclusions: Our analyses included three common indicators of health status and provide new evidence of their complex associations with cancer screening. Future studies must examine the mechanisms by which these indicators influence screening recommendations and adherence among older adults over time. [Copyright &y& Elsevier]

The article presents a study to determine the long-term outcomes of positive fecal occult blood test (FOBT) results in older adults and their associated benefits and burdens in the U.S. Data from 2001 through 2008 were collected from 212 FOBT-positive patients 70 years or older. Findings suggest that, over a seven-year period, older adults with best life expectancy were less likely to experience a net burden from current screening and follow-up practices than those with worst life expectancy.

Background: Four population-based studies of screening for CRC with fecal occult blood testing (FOBT) have shown that mortality can be significantly reduced. However, nearly half of all positive screening tests are not appropriately evaluated.Objectives: We evaluated whether an electronic record intervention improved the follow-up of patients with a positive FOBT (FOBT+) result.Design: We conducted a cluster randomized trial involving four Veteran's Affairs (VA) medical centers pair-matched by colonoscopy volume and randomized within the pair to receive the electronic intervention or usual care.Participants: All patients with FOBT+ results at participating facilities during a matched pre- and post-intervention time period.Interventions: In the two intervention sites, an electronic consult that imported relevant clinical information was automatically submitted to the gastroenterology (GI) clinic for all FOBT+ patients at the time the result was recorded in the laboratory. In both intervention and control sites (usual care), PCPs continued to be notified of FOBT+ results in the usual mannerMeasures: Pre- and post-intervention changes in the proportion of FOBT+ patients having: (1) a GI consult or (2) a GI consult plus complete diagnostic evaluation (CDE) of the colon within 30, 90 and 180 days were compared across intervention and control sites. Log rank tests were used to determine statistical significance.Results: The 30-, 90- and 180-day GI consult rates improved 21-33 % (p < 0.001) among intervention sites, but did not change in the usual care sites. Thirty-, 90- and 180-day CDE rates improved 9-31% (p < 0.03) in intervention sites, but did not significantly change in the usual care sites. Time to GI consult and CDE decreased significantly over time in the intervention sites (p < 0.001), but remained unchanged in the usual care sites.Conclusions: The relatively simple electronic intervention evaluated can significantly improve the follow-up of FOBT+ results. Interventions such as this could improve patient care and may be applicable to other practice settings, as well as other types of tests. [ABSTRACT FROM AUTHOR]

OBJECTIVES:Existing cross-sectional quality measures for colorectal cancer (CRC) screening do not assess longitudinal adherence and thus may overestimate the quality of care. Our goal was to evaluate the adherence to repeated yearly fecal occult blood tests (FOBTs) in order to better understand the extent to which longitudinal adherence may impact screening quality.METHODS:This was a retrospective cohort analysis of 1,122,645 patients aged 50-75 years seen at any of the 136 Department of Veterans Affairs medical centers across the United States in 2000 and followed through 2005. The primary outcome was receipt of adequate CRC screening as defined by receipt of FOBTs in at least 4 out of 5 years or receipt of any number of FOBTs in addition to at least one colonoscopy, flexible sigmoidoscopy, or double-contrast barium enema. In a predefined subset of patients receiving exclusively FOBT, adherence with repeated testing was determined over the 5-year study period.RESULTS:Only 41.1% of men and 43.6% of women received adequate screening. Of the 384,527 men who received exclusively FOBT, 42.1% received a single FOBT, 26.0% received 2 tests, 17.8% received 3 tests, and only 14.1% were documented to have received at least 4 tests during the study period. Among the 10,469 female veterans receiving FOBT alone, rates were similar with only 13.7% completing at least 4 FOBTs in the 5-year study period.CONCLUSIONS:Adherence to repeated FOBT is low, suggesting that cross-sectional measurements of quality may overestimate the programmatic success of CRC screening. [ABSTRACT FROM AUTHOR]

Background: Many older adults in the U.S. do not receive appropriate colorectal cancer (CRC) screening. Although primary care physicians' recommendations to their patients are central to the screening process, little information is available about their recommendations in relation to guidelines for the menu of CRC screening modalities, including fecal occult blood testing (FOBT), flexible sigmoidoscopy (FS), colonoscopy, and double contrast barium enema (DCBE). The objective of this study was to explore potentially modifiable physician and practice factors associated with guideline-consistent recommendations for the menu of CRC screening modalities.Methods: We examined data from a nationally representative sample of 1266 physicians in the U.S. surveyed in 2007. The survey included questions about physician and practice characteristics, perceptions about screening, and recommendations for age of initiation and screening interval for FOBT, FS, colonoscopy and DCBE in average risk adults. Physicians' screening recommendations were classified as guideline consistent for all, some, or none of the CRC screening modalities recommended. Analyses used descriptive statistics and polytomous logit regression models.Results: Few (19.1%; 95% CI:16.9%, 21.5%) physicians made guideline-consistent recommendations across all CRC screening modalities that they recommended. In multivariate analysis, younger physician age, board certification, north central geographic region, single specialty or multi-specialty practice type, fewer patients per week, higher number of recommended modalities, use of electronic medical records, greater influence of patient preferences for screening, and published clinical evidence were associated with guideline-consistent screening recommendations (p < 0.05).Conclusions: Physicians' CRC screening recommendations reflect both overuse and underuse, and few made guideline-consistent CRC screening recommendations across all modalities they recommended. Interventions that focus on potentially modifiable physician and practice factors that influence overuse and underuse and address the menu of recommended screening modalities will be important for improving screening practice. [ABSTRACT FROM AUTHOR]

The article presents a research which examines costs and cost effectiveness of our mailed educational reminder on adherence with fecal occult blood test (FOBT)-type screening among the U.S. veteran population. As reported, researchers conducted randomized controlled trials under which, an analysis of costs was conducted from the payer's perspective. According to the research, compared to colorectal cancer (CRC) screening, FOBT card return rate is higher with simple mailed educational reminder.

This study represents a new application of Veterans Affairs (VA) administrative data for measuring VA system-wide performance of colorectal cancer (CRC) screening adherence among veterans at average-risk for CRC. Our new measurement has two features: it is specifically designed for average-risk populations and is applied repeatedly at the veteran level each year over the study period. Using 1997-2007 VA administrative data, we developed an algorithm that first constructed 7 independent cohorts of average-risk veterans eligible for CRC screening, one for each year from 2001 to 2007, and then appended the seven cohorts together to form 2001-2007 veteran-level panel data. Veterans in a cohort for a given year were considered adherent if they received fecal occult blood test (FOBT) during that given year, or received flexible sigmoidoscopy (FS), double-contrast barium enema (DCBE), or colonoscopy during that given year or the 4 previous years. The main analysis shows that VA CRC screening rates increased from 30.11% in 2001 to 35.51% in 2004, but declined to 31.54% in 2007. Among the screened, the proportion adherent to colonoscopy increased over the 7-year period while the proportion adherent to FOBT, FS, or DCBE decreased during the same period. Sensitivity analyses, including use of a 10-year retrospective window for determining the screening adherence of colonoscopy, show the robustness of the main analysis. This new algorithm demonstrates that VA administrative data may be used for assessing VA performance of CRC screening adherence of average-risk veterans. Furthermore, our panel data may enhance understanding of factors associated with CRC screening adherence. [ABSTRACT FROM AUTHOR]

Background: Fecal occult blood testing (FOBT) is an important option for colorectal cancer screening that should be available in order to achieve high population screening coverage. However, results from a national survey of clinical practice in 1999-2000 indicated that many primary care physicians used inadequate methods to implement FOBT screening and follow-up.Objective: To determine whether methods to screen for fecal occult blood have improved, including the use of newer more sensitive stool tests.Design: Cross-sectional national survey of primary care physicians.Participants: Participants consisted of 1,134 primary care physicians who reported ordering or performing FOBT in the 2006-2007 National Survey of Primary Care Physicians' Recommendations and Practices for Cancer Screening.Main Measures: Self-reported data on details of FOBT implementation and follow-up of positive results.Results: Most physicians report using standard guaiac tests; higher sensitivity guaiac tests and immunochemical tests were reported by only 22.0% and 8.9%, respectively. In-office testing, that is, testing of a single specimen collected during a digital rectal examination in the office, is still widely used although inappropriate for screening: 24.9% of physicians report using only in-office tests and another 52.9% report using both in-office and home tests. Recommendations improved for follow-up after a positive test: fewer physicians recommend repeating the FOBT (17.8%) or using tests other than colonoscopy for the diagnostic work-up (6.6%). Only 44.3% of physicians who use home tests have reminder systems to ensure test completion and return.Conclusions: Many physicians continue to use inappropriate methods to screen for fecal occult blood. Intensified efforts to inform physicians of recommended technique and promote the use of tracking systems are needed. [ABSTRACT FROM AUTHOR]

Colorectal cancer is a significant cause of morbidity and mortality in the United States and throughout the world. The importance of this disease to gastroenterologists cannot be understated, given that screening and surveillance colonoscopy are dominant segments of clinical practice. The United States is the only country in the world where incidence and mortality rates from colorectal cancer are reported to be decreasing significantly, but health disparities in cancer screening, treatment, and survival persist. Health disparities are also evident worldwide, where the impact of this disease is staggering. In fact, rates of cancer are increasing in many parts of the world. Eliminating barriers to cancer screening and treatment could lead to substantial gains in quality and quantity of life and decrease the burden of colorectal cancer on public health. Programmatic and opportunistic screening programs have already had a measurable impact on disease burden, although the optimal screening strategy remains a matter of debate. Screening programs vary throughout the world, and further refinement will require a tailored approach because of differences in politics and fiscal reality among individual countries. Despite the strong impact of colorectal cancer on public health, there is cause for optimism and room for hope. [Copyright &y& Elsevier]

Information about several papers discussed at the State-of-the-Science conference sponsored by the National Cancer Institute and the National Institutes of Health on February 2-4, 2010 is presented. Topics include the assessment of colorectal cancer screening, the socioeconomic characteristics of colorectal cancer, and the use of fecal occult blood testing (FOBT) and flexible sigmoidoscopy. The conference featured several speakers including John Z. Ayanian, Mary Barton, and Roshan Bastani.

The article presents the recommendation statement from the U.S. Preventive Services Task Force (USPSTF) on the matter of screening for colorectal cancer in adults. The USPSTF suggests screening at age 50 until 75 years old using fecal occult blood test (FOBT), sigmoidoscopy or colonoscopy. The options of computed tomography (CT) colonography and fecal deoxyribonucleic acid (DNA) tests are considered. Also suggested is the application of dietary approaches to protect against the risk of colorectal adenomas.

In the recent 1e2 decades, we have seen a considerable development in colorectal cancer (CRC) screening modalities and programme implementation, but major challenges remain. While CRC is still the second leading cause of cancer death in both the USA and Europe, there are limited data on the efficacy and effectiveness of all screening modalities except for the faecal occult blood test (FOBT). Newer screening tests, such as faecal immunochemical tests, molecular markers and CT colonography are being introduced and variably adopted, though overall rates of screening are suboptimal. Professional societies and governmental bodies have endorsed screening, though recommended approaches are quite variable, which may help to explain the great variation in screening practices. Unfortunately, quality assurance programmes are underutilised. Comparing the USA and Europe there may be more variation in CRC screening recommendation and practice within each continent than between them, but there seems to be a stronger emphasis on programmatic screening in Europe, facilitating quality assurance. The much debated need for randomised trials as new screening modalities emerge could be more easily handled if running screening programmes are regarded as natural platforms for testing out and evaluating presumed improvements in the service‒including new emerging screening modalities. [ABSTRACT FROM AUTHOR]

Background: Colorectal cancer (CRC) is one of the leading causes of cancer-related deaths in the United States. Randomized controlled trials have shown that annual screening fecal occult blood testing (FOBT) reduces CRC mortality and incidence. However, patient compliance with FOBT is low.Objective: To determine whether a mailed educational reminder increases FOBT card return rates and to examine predictors of FOBT compliance.Design: Blinded, randomized, controlled trial at the Veteran Affairs Medical Center, San Diego, California.Patients: Seven hundred and seventy-five consecutive patients > or =50 years of age referred by their primary care physicians for FOBT.Intervention: Patients were randomly assigned to the usual care group or the intervention group. Ten days after picking up the FOBT cards, a 1-page reminder with information related to CRC screening was mailed to the intervention group only.Measurements: The primary outcome was proportion of returned FOBT cards after 6 months. Patient demographic, clinical characteristics and prior FOBT completed were collected for multivariate regression analysis.Results: At 6 months after card distribution, 64.6% of patients in the intervention group returned cards compared with 48.4% in the control group (P < 0.001). Patients who received a mailed reminder (OR 2.02; 95% CI: 1.48-2.74) or have a prior history of returning the FOBT cards (OR 1.87; 95% CI: 1.29-2.70) were more likely to return the FOBT cards. Patients with current or recent illicit drug use were less likely to return the FOBT cards (OR 0.26; 95% CI: 0.13-0.50).Conclusion: A simple mailed educational reminder significantly increases compliance with FOBT for CRC screening. [ABSTRACT FROM AUTHOR]

Abstract: Objective: To assess colorectal cancer (CRC) screening mode preferences and correlates of these preferences among US veterans at average risk for CRC. Method: A cross-sectional survey of a nationally representative sample of VA patients was conducted between January 2005 and December 2006. We report preference distributions for screening modes among 2068 average-risk veterans and across patient subgroups based on personal, behavioral, and environmental factors. Independent predictors of preferences are identified through hierarchical logistic regression models. Results: Colonoscopy (37%) was the most preferred mode followed by fecal occult blood test (FOBT) (29%). The strongest predictors of preferences were previous screening experience, provider recommendation, and use of non-VA healthcare services. Participants in higher socioeconomic groups were more likely to choose colonoscopy and less likely to indicate no preference. Conclusion: Screening programs that offer only one mode fail to accommodate the preferences of a substantial proportion of patients. Within the VA, adding screening colonoscopy to programs currently offering only FOBT is likely to increase preferences for colonoscopy, as patients incorporate provider recommendations for and personal experience with colonoscopy into their preferences. This is likely to disproportionately benefit lower socioeconomic groups who do not currently have access to non-VA colonoscopy services. [Copyright &y& Elsevier]

OBJECTIVES:Delayed diagnosis of colorectal cancer (CRC) is among the most common reasons for ambulatory diagnostic malpractice claims in the United States. Our objective was to describe missed opportunities to diagnose CRC before endoscopic referral, in terms of patient characteristics, nature of clinical clues, and types of diagnostic-process breakdowns involved.METHODS:We conducted a retrospective cohort study of consecutive, newly diagnosed cases of CRC between February 1999 and June 2007 at a tertiary health-care system in Texas. Two reviewers independently evaluated the electronic record of each patient using a standardized pretested data collection instrument. Missed opportunities were defined as care episodes in which endoscopic evaluation was not initiated despite the presence of one or more clues that warrant a diagnostic workup for CRC. Predictors of missed opportunities were evaluated in logistic regression. The types of breakdowns involved in the diagnostic process were also determined and described.RESULTS:Of the 513 patients with CRC who met the inclusion criteria, both reviewers agreed on the presence of at least one missed opportunity in 161 patients. Among these patients there was a mean of 4.2 missed opportunities and 5.3 clues. The most common clues were suspected or confirmed iron deficiency anemia, positive fecal occult blood test, and hematochezia. The odds of a missed opportunity were increased in patients older than 75 years (odds ratio (OR)=2.3; 95% confidence interval (CI) 1.3–4.1) or with iron deficiency anemia (OR=2.2; 95% CI 1.3–3.6), whereas the odds of a missed opportunity were lower in patients with abnormal flexible sigmoidoscopy (OR=0.06; 95% CI 0.01–0.51), or imaging suspicious for CRC (OR=0.3; 95% CI 0.1–0.9). Anemia was the clue associated with the longest time to endoscopic referral (median=393 days). Most process breakdowns occurred in the provider–patient clinical encounter and in the follow-up of patients or abnormal diagnostic test results.CONCLUSIONS:Missed opportunities to initiate workup for CRC are common despite the presence of many clues suggestive of CRC diagnosis. Future interventions are needed to reduce the process breakdowns identified. [ABSTRACT FROM AUTHOR]