Improving colorectal cancer screening among the medically underserved: A pilot study within a federally qualified health center

BACKGROUND: Colorectal cancer screening rates remain low, especially among low-income and racial/ethnic minority groups. OBJECTIVE: We pilot-tested a physician-directed strategy aimed at improving rates of recommendation and patient colorectal cancer screening completion at 1 federally qualified health center serving low-income, African-American and Hispanic patients. Colonoscopy was specifically targeted. DESIGN: Single arm, pretest-posttest design. SETTINGS: Urban. PATIENTS: 154 screening-eligible, yet nonadherent primary care patients receiving care at an urban, federally qualified health center. INTERVENTION: 1) manually tracking screening-eligible patients, 2) mailing patients a physician letter and brochure before medical visits, 3) health literacy training to help physicians improve their communication with patients to work to resolution, and 4) establishing a "feedback loop" to routinely monitor patient compliance. MEASUREMENT: Chart review of whether patients received a physician recommendation for screening, and completion of any colorectal cancer screening test 12 months after intervention. Physicians recorded patients' qualitative reasons for noncompliance, and a preliminary cost-effectiveness analysis for screening promotion was also conducted. RESULTS: The baseline screening rate was 11.5%, with 31.6% of patients having received a recommendation from their physician. At 1-year follow-up, rates of screening completion had increased to 27.9 percent (p <.001), and physician recommendation had increased to 92.9% (p <.001). Common reasons for nonadherence included patient readiness (60.7%), competing health problems (11.9%), and fear or anxiety concerning the procedure (8.3%). The total cost for implementing the intervention was $4,676 and the incremental cost-effectiveness ratio for the intervention was $106 per additional patient screened by colonoscopy. CONCLUSIONS: The intervention appears to be a feasible means to improve colorectal cancer screening rates among patients served by community health centers. However, more attention to patient decision making and education may be needed to further increase screening rates.