The intervention that we have described and pilot tested in this study targeted improvement in colorectal cancer screening completion rates, specifically colonoscopy, among community health centers serving the needs of indigent and racial/ethnic minority patients. Based on our findings, this strategy appears to have had a substantial impact on physician recommendation and patient screening participation, specifically for colonoscopy. This is notable, as previous studies have referred to colonoscopy as arguably a harder behavior change for patients compared to less invasive tests such as FOBT.22–24
The cost-effectiveness estimates for promoting colorectal cancer screening within an FQHC, especially if a medical assistant conducted chart audits, were found to be similar to the lowest previously reported estimates for mammography and pap smears.14,17
These estimates were also lower than what had been reported in the initial clinical trial of this intervention strategy among veterans.14
Despite sizable increases in physician recommendation and patient colorectal cancer screening completion rates, the proportion of those who completed screening after receiving a recommendation remained relatively constant from baseline to postintervention. This is much lower than what was anticipated based on our prior research among FQHCs, and what had been achieved among veterans.10
It is possible that the emphasis on colonoscopy as the practice standard in this intervention led to a lower uptake of recommended screening. However, the increase in recommendation rates alone was enough to increase screening completion rates, reinforcing the importance of the physician’s role in screening adherence. We previously found that 95% of patients within this FQHC network were screened by FOBT. This is in part supported by our qualitative findings that patient readiness was the most common reason for nonadherence to colonoscopy.
In addition, it is informative to learn that patients who received 2 or more recommendations from their physician during the study period were less likely to complete a screening test compared to those who only discussed the topic once with their physician. This could be attributed, again, to patient readiness. Trauth and colleagues25
estimated the prevalence of patients across the stages of change for colorectal cancer screening. Patients were more likely to be at the earlier precontemplation and contemplation stages for endoscopic procedures compared with FOBT. Among our sample of patients, many might still be struggling to accept colonoscopy as a screening procedure they can pursue, especially if they did not perceive they had less invasive options or had previous experience with the FOBT.
The inclusion of a cost-effectiveness analysis provided support for the feasibility of the intervention within a community health center. The efficacy of the intervention coupled with the relatively low cost associated with promoting colorectal cancer screening makes the strategy appealing to health care systems and clinics with few resources. The use of a medical assistant or health paraprofessional within an FQHC offers additional cost savings, pending confirmation of their ability to navigate chart information on colorectal cancer and screening. Costs could be dramatically reduced even further if the chart audit was automated.14,26
Currently, only 8% of FQHCs have an electronic medical record. This may rise in the near future as necessary resources to implement a system become more easily attainable.14,27,28
Both the inclusion of an automated tracking system and the use of nonphysician staff should be tested in subsequent trials.
Our study clearly has many limitations. First, screening-eligible adults were identified by age only; information on patients with an identified family history of colon cancer or polyps was not available without a much larger scale manual chart review. Second, there is a remote chance that patients sought or received screening information or services elsewhere, which would not be captured in our analyses. However, our inclusion of patients who were more frequent users of care at the FQHC, and their limited economic resources suggest the patients included in our study are not as likely to be dual users of a preventive care service like colonoscopy or FOBT.10,22
Third, several other patient-level characteristics have been previously proposed as influencing screening adherence, but were not captured in the current research activities.22
Fourth, we recognize the value of the support of a community hospital to provide charitable care to patients with financial restrictions was crucial for the implementation of this intervention. Finally, this was a pilot test using a single-group, pretest–posttest design only. Our findings do not represent definitive evidence of the intervention’s efficacy, as the design itself cannot account for potential bias from patient selection, maturation, or other unmeasured, external influences (e.g., competing screening promotion efforts). A proper evaluation of our strategy within the context of a controlled clinical trial at multiple FQHCs will be necessary in the future.
Our provider-directed intervention had a strong showing in this single-clinic pilot study, yet these findings suggest there are ways in which it could be improved. For instance, decision-making activities should be broadened to include physician–patient discussions of more than 1 of the available screening tests, not just colonoscopy. This might help patients find a test that is most acceptable to them.16
Further, considerations for other patient educational materials, such as multimedia tools and those that are deemed “enhanced print” for low literacy populations, might be necessary to support the most effective screening messages to be delivered to patients.16,29,30
Also, more intensive low-literacy communication and motivational interviewing skills training may be needed for physicians at these clinics to make more effective recommendations that coincide with messages in the patient materials.13
These changes may lead to more marked improvement in screening recommendation and behavior, although the additional cost of this revised strategy’s implementation should also be evaluated.