System-Level Barriers to Follow-up Colonoscopy Completion After Positive Fecal Test: Interviews With Gastroenterologists and Staff

Background: Despite the efficacy of colorectal cancer (CRC) screening, many adults are not screened at recommended intervals or screened at all. Federally qualified health centers (FQHCs) serve a unique patient population that often experience barriers to CRC screening. Yearly fecal testing and colonoscopy follow-up for positive test results can reduce CRC incidence and mortality. However, many patients with positive fecal test results forgo follow-up colonoscopy, nullifying the potential benefits of fecal testing. Methods: As part of the Strategies and Opportunities to STOP Colon Cancer in Priority Populations (STOP CRC) study, we qualitatively explored factors associated with referral to and completion of follow-up colonoscopy after a positive fecal test. Through interviews with gastroenterologist (GI) providers and office staff, we sought to elucidate system-level barriers to colonoscopy completion and identify areas for improvement for patients referred from FQHCs. Specialists and their staff were recruited via email, and interviews were conducted in-person or by phone using an interview guide. Interviews were recorded, transcribed, coded and content-analyzed by trained qualitative staff, resulting in refined themes. Results: We completed 15 in-depth interviews with GI providers (n = 8) and office staff (n = 7). The most frequently cited challenges by all interviewees related to increase in demand following the Affordable Care Act, complexity and time delay issues with insurance requirements, and inadequate staffing at the specialist office. GI providers emphasized capacity issues, including long wait times and limited appointment options. Office staff highlighted lack of complete referral and medical review documentation and language barriers. Improving communication and electronic referral documentation between the FQHC and GI office was identified by participants as vitally important. GI providers also advised on the need to reduce no-show rates and improve scheduling; and office staff desired preparation instructions in additional languages and skilled interpreters to attend the colonoscopy procedure with the patient. Conclusion: The life-saving benefits of CRC screening can be maximized by identifying challenges to follow-up colonoscopy after a positive fecal test. Uncovering system-level issues and possible areas for improvement in referral coordination and procedure completion can further contribute to increasing CRC screening rates for patients receiving care in FQHCs