Increasing Procedure Access with Stool-Based Tests for Average Risk Patients Who Are Scheduled for a Colorectal Cancer Screening Colonoscopy

Colorectal cancer (CRC) is the second leading cause of cancer-related death among men and women in the US. CRC is now the number one cause of cancer death for men under 50 and the second cause of cancer death for women in that age group, although it may be prevented through screening. When colorectal cancer is found in early stages, nine out of ten people have no evidence of their cancer five years later. Regular screenings are recommended starting at age 45.
Colonoscopy was once widely regarded as the gold standard for CRC screening since precancerous growths can be removed during the procedure. However, patients at one of the health system’s major medical centers were facing an 18-month wait for a screening colonoscopy. Like many organizations across the nation, multiple factors such as specialist shortages, guidelines lowering the recommended screening age to 45 from 50, increased prioritization of screening, and other influences have contributed to a growing delay to procedure access. While colonoscopy is the sole screening option for patients with traditional risk factors, those without factors (average risk) have three options at our organization: colonoscopy or the stool-based tests called fecal immunochemical test (FIT) or sDNA-FIT (Cologuard).
Objective: To increase colonoscopy access for patients who require timeliness by removing at least 30% of targeted average-risk patients from the colonoscopy waiting queue through alternate testing, using an opt-out mailed stool test outreach model.
Methodology: The performance improvement project team created a report to identify patients meeting agreed-upon eligibility criteria as determined by physician leaders and other relevant experts. Over seven weeks, eligible patients were sent a primer communication through their patient portal or mail, per preference settings in the electronic medical record (EMR). The communication explained a pre-determined test (FIT or Cologuard) would be mailed to their home in the coming weeks unless the patient opted out by notifying the centralized project team via one of three methods: website, call center, or PCP clinic. Patients who appeared as self-pay in the EMR were called by the team. They were screened for eligibility and had test options reviewed, and if they confirmed self-pay, they were offered a referral to a trained financial advocate, regardless of modality chosen.
Two weeks after the communications were sent, a bulk order was placed by a nurse with the test vendor who prepared and mailed the tests.
Results: After sending 1,248 patient (intent to treat (ITT) population) primer communications, bulk orders were placed for 1,183 (94.8%) kits over the course of seven weeks. Opted out notifications were received for 314 patients (25.2%), with most reported they had a change in personal health (121 patients) which met heightened risk criteria, or they prefer colonoscopies (120 patients). Valid results were received for 457 patients (36.6% of ITT), with 42 positive results (9.2% positive rate) requiring a follow-up colonoscopy. The project removed 415 patients (33.3% of ITT) from the waiting queue, reducing the wait by approximately two months.