Improving the completion rate of outpatient stool-based colon cancer screening during a global pandemic.

238 Background: Colon Cancer Screening is an important intervention to reduce the morbidity and mortality of colorectal cancer. In particular, stool based screening tests help to increase the availability of screening especially amidst a global pandemic. However stool based screening is limited by patient return rates of FIT/iFOBT tests. Here at the Austin Outpatient VA we sought to improve the FIT test return rate of patients in our resident clinic by at least 20%. Methods: We did a root cause analysis as to why iFOBT/FIT were not being returned, particularly during the height of the pandemic when most visits were virtual. With help from the VA data core we generated a list of 76 patients during a period from 2/3/2020-7/7/2020 who had not returned an ordered FIT/iFOBT test in >30 days. We called these patients to identify the reasons why they did not return their test. Results: We were able to reach (44/76) patients and discovered that only (12/44) 27.3% of patients contacted had received a FIT test. Of our patients-reached 33/44 of them asked for a new FIT test to be sent to them and ultimately (21/44) patients contacted returned and completed their FIT test successfully with 3 tests being positive and referred to diagnostic colonoscopy. This resulted in an improvement in return rate of ̃47% of all patients ultimately contacted. Conclusions: Through a meeting of stakeholders including nurses and resident physicians we discovered in our EMR, that the order to send out a FIT test does not automatically alert a nurse nor does it automatically mail out or send out a FIT test. We discovered there was not a standardized process in place to facilitate communication between physicians ordering tests and nurses, thus FIT/FOBT tests were not being sent. We are currently working on a process to standardize the FIT test ordering process to improve communication between physicians and nurses. We are developing a better order set that reminds providers to alert and message nurses prior to ordering the FIT/iFOBT test. We are also educating Residents about the FIT/FOBT ordering process. With future PDSA cycles we should be able to improve the robustness and reliability of our outpatient colon cancer screening process through improved inter-professional communication.

The Effect of Nomenclature Revision of Streptococcus bovis to Streptococcus gallolyticus on Subsequent Colon Cancer Screening

Background Lack of awareness of the taxonomic revision from the familiar Streptococcus bovis to the less familiar Streptococcus gallolyticus may be associated with a decrease in recommended colon cancer screening in patients with bacteremia from this organism. This could subsequently lead to a delay in diagnosis or underdiagnosis of colon cancer and other serious underlying gastrointestinal diseases. The aim of this study was to determine whether the nomenclature change of S. bovis to S. gallolyticus resulted in decreased colon cancer screening. Methods This study was a retrospective, observational, nationwide analysis of patients who had positive blood cultures for S. bovis/S. gallolyticus from any Veterans Affairs Medical Center (VAMC) between January 1, 2002, and December 31, 2017. Results There was no difference in the primary end point of intent for colonoscopy between the S. gallolyticus and S. bovis groups (66.5% [117/176] vs 62.1% [624/1005], respectively; P = .26). The overall mortality rate was 33.8% among 1181 patients included in the study, with a significantly lower mortality in patients with evidence of intent for colonoscopy (29.6% vs 42.5%; P ≤ .001), gastroenterology (GI) consultation (29.8% vs 41.4%; P < .001), infectious diseases (ID) consultation (29.4% vs 39.0%; P = .001), or either consultation (31.9% vs 40.7%; P = .013), compared to those that did not. Conclusions There was no difference in colon cancer screening rates between patients with episodes of bacteremia reported as S. bovis and those reported as S. gallolyticus. Overall mortality was lower in patients who had ID consultation, GI consultation, or evidence of colonoscopy.

Increasing uptake of colon cancer screening in a medically underserved population with the addition of blood-based testing

Background Adherence to colorectal cancer screening in the United States is suboptimal, particularly in medically underserved populations due to significant barriers to care. Unique accessible, low-cost, and non-invasive screening tests for this population could greatly benefit current rates. In this article, we assess patient preference and the impact of offering a blood-based test on screening rates in a cost-free health fair setting from April 2017 to April 2019. Methods Participants who met colorectal cancer screening eligibility criteria set forth by the United States Preventive Services Task Force were recommended to attend the colon cancer screening station. Those participants who elected to attend were offered various, accepted screening methods, and if they declined, were offered alternative blood-based testing. Screening rates, test outcomes, and the rate of follow up completion of colonoscopy were measured and compared with historic screening outcomes. Results Of 1401 participants who were recommended to attend, 640 (45.7%) participants were evaluated at the colon cancer screening station, of whom 460 were eligible for testing. Amongst these, none selected colonoscopy, 30 (6.5%) selected fecal immunochemical testing, and 430 (93.5%) selected blood-based testing. Only 2 participants returned the fecal immunochemical tests. In the blood test cohort, 88 were positive and 20 received a follow up colonoscopy. Conclusions Based on this assessment, blood-based testing is an effective method to increase screening rates in medically underserved populations, though efforts to further improve access to follow up colonoscopy are necessary.

Layperson Views about the Design and Evaluation of Decision Aids: A Public Deliberation

Purpose We carried out the first public deliberation to elicit lay input regarding guidelines for the design and evaluation of decision aids, focusing on the example of colorectal (“colon”) cancer screening. Methods A random, demographically stratified sample of 28 laypeople convened for 4 days, during which they were informed about key issues regarding colon cancer, screening tests, risk communication, and decision aids. Participants then deliberated in small and large group sessions about the following: 1) What information should be included in all decision aids for colon screening? 2) What risk information should be in a decision aid and how should risk information be presented? 3) What makes a screening decision a good one (reasonable or legitimate)? 4) What makes a decision aid and the advice it provides trustworthy? With the help of a trained facilitator, the deliberants formulated recommendations, and a vote was held on each to identify support and alternative views. Results Twenty-one recommendations (“deliberative conclusions”) were strongly supported. Some conclusions matched current recommendations, such as that decision aids should be available for use with and without providers present (conclusions 1–4) and should support informed choice (conclusion 9). Some conclusions differed from current recommendations, at least in emphasis—for example, that decision aids should disclose cost of screening (conclusion 11) and should be kept simple and understandable (conclusion 14). Deliberants recommended that decision aids should disclose the baseline risk of getting colon cancer (conclusions 15, 17). Limitations Single location and medical decision. Conclusions Guidelines for design of decision aids should consider putting a greater focus on disclosing cost and keeping decision aids simple, and they possibly should recommend disclosing less extensive amounts of quantitative information than currently recommended.