We evaluated the association of patient adherence for scheduled out-patient endoscopy by time of day, day of week and the season. We observed that patients were more likely to be compliant with their procedures as the week progressed from Mondays to Fridays and in the warmer months, particularly for colonoscopy. In our institution, colonoscopy is the dominant screening method for colorectal screening. While multiple factors may influence patients’ compliance, our study suggests that when feasible, patients that are envisaged to have challenges with being compliant with their medical care may be better scheduled in the latter days of the week. Nonetheless, other efforts to improve adherence are needed. As part of our quality improvement, we have added another staff member to handle our endoscopy schedule and call patients five days prior to their procedures and report any challenges directly to the endoscopist. We plan to evaluate the effect of this intervention in the nearest future.
Evidence suggests that screening colonoscopy can reduce the incidence and mortality from colorectal cancer (17
). However, despite availability and access to such procedures a large proportion of patients, particularly African Americans, are not up to date with screening recommendations (15
). Healthcare access has been suggested as a possible explanation for this; however our population for the most part was insured. Previous studies have demonstrated that patients with access to healthcare can still fail to complete colonoscopic screening even though the procedure was recommended by and discussed with their primary care physician (1
). In open access settings (where the primary care physician can schedule their patients directly without prior consultation with a gastroenterologists), non-compliance as high as 40% have been reported for colonoscopy (1
). In our institution where the endoscopist performing the procedure meets the patient prior to scheduling, we observed improved compliance but 20% non-compliance is still a substantial waste of resources.
Our patients were educated about the importance of the procedure and any questions or concerns were addressed during the initial clinic consultation. Patients were also provided with an educational pamphlet with additional information that included instructions for cancellation of the procedure. Most procedures were scheduled within 2–4 weeks from the date of the first encounter with the endoscopist on a day and time that was convenient for the patient. Thus, health system barriers such as scheduling challenges and long waiting times probably did not contribute to patient absenteeism in our population. In addition, a phone reminder was also provided the day prior to the procedure even though this information was not tracked. The use of patient navigators may improve adherence (24
), but this will be at an additional cost or as an externally funded demonstration project.
Some recent studies have shown that polyp detection rates vary by time of day and scheduling sequence during the same shift (8
). Chan et al. (8
) reported that early morning colonoscopy yielded 27% more polyps than later procedures. Sanaka et al. (9
) in their retrospective study of 3,619 colonoscopies also reported that the adenoma detection rate was 1.2 times higher for morning procedures. We did not find any difference in compliance whether patients were scheduled in the morning or afternoon.
We noted an improved adherence particularly for colonoscopy as the week progressed, with lowest adherence on Mondays and Tuesdays. This is comparable to the findings of Adams et al. (26
). In their review of 2,157 scheduled out-patient procedures in a tertiary referral public hospital in Australia, the authors reported that 263 (12.2%) were non compliant. They noted that 39% of the non attended procedures were scheduled on Mondays, 22% on Tuesdays but the best compliance was noted on Wednesdays with only 5% of non attended scheduled procedures. Compliance was worse on Mondays and Tuesdays in our study too, but compliance was best for Friday procedures. We speculate that the poor adherence for Monday procedures may be due to patients having other challenges on the weekend that interfered with the bowel preparation demands or due to increased home and work commitments at the beginning of the week.
We hypothesized that patients were likely to be more compliant with out-patient endoscopy during winter months since “there is not much else to do”. However, our data suggest that patients are actually more compliant during the warmer months. We are not aware of any previous study that has evaluated seasonal variation in compliance with scheduled endoscopic procedure for comparison with our study. However, Segarajasingam et al. (27
) also reported that colorectal cancer screening with CT colonography was lower during winter months in their study. Further studies are needed to evaluate seasonal variation in uptake and yield of colorectal cancer screening since this may have important resource allocation implication particularly in regions with challenging weather conditions. If patients are indeed less compliant during colder months, additional interventions such as transportation assistance should be provided at this time of the year.
A major strength of our study is that we studied a large population of underserved men and women. Furthermore, the practice in our institution enabled us to reduce the contributory reasons for non adherence identified in previous studies such as long intervals between scheduling and procedure, lack of initial consultation by endoscopist, and lack of health insurance coverage. Our study has its limitations. This was a retrospective study and we reported a single institution’s experience. Furthermore, we did not have other information such as highest education attained, comorbidities, lifestyle factors (such as body mass index and smoking status) and the presence of other significant social ties which may also affect compliance (28
In conclusion, we found a substantial rate of non compliance among our underserved population with limited predictive pattern by timing of the procedures. Perhaps, scheduling procedures in the morning, offering later weekday endoscopy time and increasing institutional logistic support (such as transportation) during winter for underserved patients with compliance challenges may improve adherence. Since the utilization of colonoscopy as a screening modality is increasing while the usage of other screening modalities is either decreasing, not widely available or not covered by third party payers, targeted interventions to reduce no shows for colonoscopy will be necessary to reduce colorectal cancer disparity.