PROACT: Promoting Follow-up of Abnormal Colorectal Cancer Screening Tests through Multilevel Interventions

Project Summary/Abstract Colorectal cancer (CRC) deaths have continuously decreased since the early 1990's, yet populations that receive care in safety-net healthcare systems, which represent 25% of all U.S. hospitals, have relatively poorer CRC-related outcomes compared to their counterparts. Safety-net healthcare systems disproportionately care for lower socioeconomic status individuals, minoritized groups, and other populations with high CRC-mortality due to lack of access to care. Fecal immunochemical test (FIT) is preferred for CRC screening in safety-net healthcare systems due to low-cost and ease of completion, however only 33% to 58% of patients in safety-net healthcare systems complete a follow-up colonoscopy within 1 year of an abnormal FIT. This failure to follow- up carries a 3-fold increased risk of advanced-stage CRC and a 2-fold increased risk of dying from CRC. Greater than 6-month delays in follow-up colonoscopy are associated with an increased risk of any CRC and advanced stage CRC. Previous research has shown that obtaining a follow-up colonoscopy is a complex process for safety-net patients due to multiple barriers at multiple levels of care, including lack of transportation, fear of colonoscopy, and fragmented care in a resource-constrained health system. To address these barriers, our project aims to evaluate a multilevel intervention for follow-up colonoscopy in a safety-net healthcare system compared to usual care. This study takes advantage of several single-level interventions that have been developed, tested and implemented at Harborview Medical Center (HMC) and Kent/Des Moines (KDM) clinic, safety net health settings in Seattle, WA. These interventions include: 1) a health system- level centralized CRC program aimed to improve screening and follow-up colonoscopy, 2) a health system- level navigation to follow-up colonoscopy program, 3) a patient-level rideshare program to address transportation barriers; and 4) a patient-level video to reduce fear of colonoscopy. We propose to evaluate these interventions together as a novel, multilevel intervention that addresses multiple barriers to follow-up colonoscopy at the patient- and health system-level versus usual care (centralized CRC screening and navigation to colonoscopy). Our central hypothesis is that a multilevel intervention that addresses multiple patient- and health system-level barriers simultaneously, will significantly increase the proportion of patients who receive a follow-up colonoscopy, compared to usual care, and will be possible to implement in a safety-net setting. To test our hypothesis, we will conduct a pragmatic randomized controlled trial of HMC and KDM safety-net patients with abnormal FIT results, randomized 1:1 to the multilevel intervention vs usual care. Our specific aims are: 1) Assess the effectiveness of the multilevel intervention at improving follow-up colonoscopy completion in a safety-net population compared to a health system-level only intervention (usual care); 2) Evaluate the facilitators and barriers to the reach, acceptability, fidelity and implementation of the multilevel intervention; and 3) Evaluate the cost of implementing the multilevel intervention in a safety-net population.