Efforts to increase the number of screening colonoscopies performed and enhancements to improve operational efficiency of the GI Suite at Lincoln Medical Center appear to have been highly successful, due in large part to the influence of patient navigators and a streamlined referral system. It's difficult to tease out the individual contributions of each, as well as other contributing factors, but it seems reasonable to conclude that all, in one way or another, made an impact. By comparing the difference in the monthly coverage rates before and after the implementation of the combined Patient Navigator/DERS intervention, it was possible to evaluate the impact of the entire intervention. The broken appointment rate declined immediately after the patient navigators started at Lincoln Hospital and before the implementation of the DERS. It was therefore possible to attribute the reduction in the broken appointment rate and the associated increase in screening colonoscopy to the patient navigation component of the intervention. Though it was not possible to discern the relative contribution of each component of the intervention but only their combined impact, it is clear that both of these factors increased the number of screening colonoscopies delivered at Lincoln Hospital.
Other contributing factors to the success of the intervention appear to include the hiring of a new Chief of GI who has a commitment to increasing screening colonoscopies and a willingness to try the direct endoscopic referral system (DERS). Additionally, the surgical endoscopists at Lincoln Medical Center agreed to expand their coverage to include screening colonoscopy. Finally, the GI suite was expanded and enhanced to streamline colonoscopy procedures. Since most of these enhancements anteceded the increase in colonoscopies and reduction in the broken appointment rates, it is difficult to assess their impact. However, they may have contributed to the sustainability of the intervention.
Cancer ranks second in the causes of death among residents of Highbridge and Morrisania, and the death rate due to all cancers is 50% higher there compared with the rest of NYC.14
In a recent telephone survey conducted by the New York City Department of Health and Mental Hygiene, only 44% of adults aged 50 or over in Highbridge and Morrisania reported ever being screened for colorectal cancer by any modality (colonoscopy, sigmoidoscopy, or FOBT);14
the citywide average was 50%. Also, 41.7% of persons reported having received a colonoscopy in the preceding 10 years, 9.5% had a sigmoidoscopy in the last 5 years, and 31.9% reported an FOBT in the preceding 2 years.8,15
The efforts at Lincoln Medical Center appear to have resulted in a sustained increase in the coverage of colonoscopy in the surrounding neighborhoods.
There are several limitations of this analysis worth noting. First, the evaluation utilized a before and after comparison. Since there was no concurrent internal comparison group, we cannot rule out the possibility that some other factor that changed during the course of the intervention is responsible for the observed increase. Additionally, due to limited staff and resources, we had very little data on patients who received colonoscopies and almost no data on those referred who didn't receive colonoscopies. Ideally we would have had interviewed all or a sample of patients in each group to assess perceived barriers and enabling factors for the receipt of screening colonoscopy. We could not assess the degree to which patients who missed appointments were subsequently rescheduled and received colonoscopy. As such, we may have overestimated the broken appointment rate in our study. Finally, because of changes in the way that race/ethnicity data were collected during the study period, we could not reliably assess changes in colonoscopy rates and coverage by race/ethnicity.
The results of our investigation suggest that there are health care system barriers to patients receiving screening colonoscopy that, when addressed, can result in substantial improvements in the coverage of screening colonoscopy in the surrounding communities. Other types of barriers outside the health care system exist at the individual (e.g., knowledge of the need for screening and employment status) and community levels (e.g., lack of a nearby medical facility or access to public transportation) and should also be addressed. Individual-level barriers to receiving colorectal cancer screening and colonoscopy appear to include age, race/ethnicity, income, and insurance.9,15
Education and a lack of awareness of the need to be screened has been shown to be associated with the likelihood of screening for colorectal and other cancers.6,16
Characteristics of the physical and social environment in neighborhoods, peer and social networks, public policies and interventions, and access to quality health care may also affect the likelihood of practicing preventive behaviors such as cancer screening and the subsequent risk of disease.17–19
For example, “neighborhood social environment” has been associated with hypertension,20
low birth weight21
and high-risk sexual behaviors among women.22
As Diez Roux has argued, “[n]eighborhood differences are not ‘naturally’ determined but rather result from social and economic processes influenced by specific policies. As such, they are eminently modifiable and susceptible to intervention.”18
The role of such factors as barriers to receiving timely colorectal cancer screening has not been systematically studied and may yield important information for future interventions to improve colorectal cancer screening rates.