Barriers and Facilitators of Colorectal Cancer Screening in a Federally Qualified Health Center (FQHC)

Kelly R. Ylitalo, PhD; Brendan G. Camp, MPH; M. Renée Umstattd Meyer, PhD, MCHES; Lauren A. Barron, MD; Gabriel Benavidez, BS; Burritt Hess, MD; Ryan Laschober, MD; Jackson O. Griggs, MD

Disclosures

J Am Board Fam Med. 2019;32(2):180-190. 

In This Article

Results

Patients age ≥50 years of age who received a FIT order between January 1, 2017 and July 1, 2017 are described in Table 1. Approximately two thirds (63.2%) were female and the mean [SD] age was 59 [7.11] years. Most patients (n = 392; 44.8%) were Hispanic/Latino, one quarter (n = 213; 24.3%) were non-Hispanic black, and almost one third (n = 259; 29.5%) were non-Hispanic white. Most patients were self payers (n = 415; 47.4%). Mean [SD] BMI was 30.90 [7.76] kg/m2 and over half (n = 482; 55.1%) were defined as obese. Approximately one quarter were current smokers (n = 194; 22.2%). Patients who returned the FIT (n = 440) were comparable to patients who did not return the FIT (n = 435) in terms of sex, insurance status, and BMI, but nonreturners were more likely to identify as non-Hispanic black and more likely to be current smokers. See Table 1 for more detail.

Patients who identified as non-Hispanic black had a marginally increased risk of FIT nonreturn (RR = 1.18 [95% CI, 0.99, 1.40]) and patients who identified as non-Hispanic other had an increased risk of FIT nonreturn (RR = 1.49 [95% CI, 1.02–2.19]) compared with non-Hispanic white patients. Patients with public insurance were at increased risk of FIT nonreturn compared with patients with private insurance (RR = 1.21 [95% CI, 1.01–1.44]). Self-payers, including those who paid a discounted fee based on a sliding scale, had a lower risk of FIT nonreturn compared with patients with private insurance (RR = 0.85 [95% CI, 0.73–0.99]). Current smokers were at increased risk of FIT nonreturn compared with never smokers (RR = 1.32 [95% CI, 1.13–1.54]). After adjusting for all patient characteristics in multivariate models, current smokers remained at increased risk for FIT nonreturn (Table 2).

Among patients who did not return the FIT (n = 435), 121 patients participated in a telephone survey. The 121 patients who participated in the survey were less likely to identify as non-Hispanic black but were otherwise similar to patients who did not participate in terms of age, sex, insurance status, BMI, and smoking status (results not shown). The most common barriers to FIT return reported by patients were forgetfulness (61%), lack of motivation (51%), and fear of embarrassment (31%). Clinicians perceived the most common patient barriers to FIT return were lack of motivation (81%), forgetfulness (61%), fear of embarrassment (55%), and FIT instructions (55%). Patients reported that prepaid postage with return address on FIT return envelopes (77%), live call reminders (73%), and reminders by text message (60%) would be helpful to FIT return. Clinicians reported that prepaid postage envelopes with return address (71%), live call reminders (52%), and better FIT instructions (45%) would be helpful to increase patient FIT return (Table 3).

We compared FIT barriers and facilitators by insurance status, race/ethnicity, and language preference. Patients who participated in the telephone survey (n = 121) were privately insured (n = 30; 25%), publicly insured (n = 26; 21%), or self payers (n = 65; 54%). There were no statistically significant differences in barriers and facilitators between insurance groups, with the exception of live call reminders to facilitate FIT return: 23 patients with private insurance (77% of the 30 patients with private insurance), 13 patients with public insurance (50% of the 26 patients with public insurance), and 52 self payers (80% of the 65 self-pay patients; P = .03 across groups) preferred live call reminders. Patients who participated in the telephone survey were Hispanic/Latino (n = 48; 40% of the 121 telephone participants), non-Hispanic black (n = 28; 23% of the 121 telephone participants), and non-Hispanic white (n = 45; 37% of the 121 telephone participants); there were 94 (78% of the 121 telephone participants) English speakers and 27 (22% of the 121 telephone participants) Spanish speakers. Race/ethnicity and language preference demonstrated similar patterns of FIT return barriers and facilitators (Table 4 and Table 5). Of note, Hispanic/Latino patients and Spanish-speaking patients were more likely to report test instructions as a barrier to the FIT, and more likely to report better test instructions, more educational materials, and more time with their clinician as FIT facilitators (Table 4 and Table 5).

Finally, we identified clinician-preferred colorectal cancer screening methods. Almost all (n = 30; 97% of the 31 participating) clinicians reported they would recommend a colonoscopy for insured patients, and 21 (68% of the 31 participating) clinicians would recommend stool-based tests (FITs and gFOBTs) for uninsured patients.

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