LAUSR

Almost 15 years ago, a review by Yabroff et al reported that incomplete follow up abnormal breast cancer, cervical cancer, and colorectal cancer (CRC) screening tests with a complete diagnostic evaluation (CDE) was common in primary care. More recently, Zapka et al found that although CDE rates have improved for abnormal mammography and Papanicolaou test screening results, there has been little improvement in CDE performance in primary care settings where stool blood testing is offered as an opportunistic screening strategy. In primary care, colonoscopy every 10 years and fecal immunochemical tests (FITs) are the most commonly recommended CRC screening tests. In primary care practice, providers may offer colonoscopy screening initially and then make FIT screening available to those patients who decline to undergo endoscopy. Although this strategy provides access to both screening tests, it serves to elevate colonoscopy as the more desirable first-tier screening test and positions FIT as a second-tier test. Alternatively, some health systems and Federally Qualified Health Centers (FQHCs) are mailing FITs directly to primary care patients. This strategy can help to maximize CRC screening rates. In those instances where an FIT is completed and there is an abnormal test result, diagnostic colonoscopy is the recommended approach to a CDE. Bharti et al address the problem of failing to follow up abnormal FIT results in primary care settings where opportunistic screening takes place. They also highlight the fact that this gap in care is a serious matter, especially in populations that experience CRC-related disparities. The authors highlight this problem in FQHCs and present findings from analyses of data collected from 8 FQHCs located in San Diego, Imperial, and Los Angeles Counties. Each participating FQHC analyzed medical record data on colonoscopy performance for at least 150 consecutive patients who had an abnormal FIT result during an observation period from January 2015 through 2016. The primary outcome of the study was colonoscopy performance within 6 months. Secondary outcomes focused on provider referral of patients for colonoscopy within this timeframe and the type of FIT used. Participating FQHCs provided aggregate, de-identified data on patient follow-up, patient demographics, the brand of FIT kit that patients used, and patient colonoscopy referral. The authors reported that 89% of patients with an abnormal FIT result were referred for follow-up colonoscopy within 6 months, but only 44% actually underwent diagnostic colonoscopy. This level of follow-up is consistent with the poor CDE rates reported in cited Veterans Administration, safety net, and other FQHC-based studies. An important strength of this study is that a relatively large number of FQHCs in a defined geographic area participated in the study. Even though participating FQHCs represented only 40% of the 20 FQHCs targeted for inclusion, the surprisingly low level of CDE performance in this and other published reports are concerning, and they support the authors’ call for a CDE to be defined as a quality metric in CRC screening. Taking this step may help to encourage health systems and primary care providers to pay greater attention to helping patients to overcome barriers to appointment scheduling and appointment keeping. The current study shows that provider colonoscopy referral rates are were quite high. In this regard, it appears that the participating FQHCs had strategies in place to facilitate provider referral of patients with abnormal FIT results for a CDE. A description of those strategies would have been useful because they seem to have largely, but not completely, addressed provider barriers to CDE performance. These findings make clear the need to learn more about