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Why Don’t Patients Access Follow-Up Care, Screenings?

Hesitance and limited knowledge about invasive screenings are getting in the way of patient access to follow-up care, but shared decision-making may help, researchers contend.

A new Dutch study is recounting the reasons why some patients don’t access follow-up care or screenings after producing a positive result on at-home colorectal cancer tests, suggesting that healthcare providers need to provide more guidance to prompt patient access to preventive care.

The study, published in the Annals of Family Medicine by the American Academy of Family Physicians, should be applicable globally as it zeroes in on human and patient behavior, the researchers said.

The advent of the at-home colorectal cancer test, such as a fecal immunochemical test or FIT, has made it easier for patients to detect if they might have the illness. That early detection is critical to a good prognosis, but only if the patient follows up that FIT with a more intensive colonoscopy.

But according to the research, that access to follow-up care and screening doesn’t always happen. In a separate 2020 study completed in the US, colonoscopy follow-up rates after an unfavorable FIT result hung at around a third, which could put patient outcomes at risk.

According to the Dutch researchers, the reasons for follow-up non-adherence could be varied. The team gathered survey responses from 2,225 people enrolled in the country’s colorectal cancer screening program and who had a positive FIT result. Follow-up colonoscopy access in this population was around the same as in the US study—33 percent.

Around half of those who didn’t access a colonoscopy had a contraindication preventing them from doing so.

But for the remaining half, the Annals researchers said participants didn’t have access to strong enough patient navigation to overcome their own personal hesitancies.

Participants reported some decision-making challenges, like having concerns about having a colonoscopy. They also told the researchers they did not have an opportunity to discuss their FIT result with their provider and that they estimated that they had a low risk of actually having colorectal cancer.

Others stated that they had an alternative explanation for having a positive FIT result that was not colorectal cancer, while others said they could self-monitor colorectal cancer or that polyp removal would be an ineffective colorectal cancer treatment, anyways.

“Participants who felt they lacked the opportunity to discuss the positive FIT, had difficulty deciding on colonoscopy participation, or were uncomfortable with an unfamiliar colonoscopy location more often did not follow up with colonoscopy,” the researchers added.

But aside from those barriers to follow-up care, there was one factor that could positively predict patient access to colonoscopy screening: provider endorsement. Patients who discussed colonoscopy follow-up with their providers, or who at least thought their primary care provider would be supportive of following a positive FIT with colonoscopy, were more likely to actually close that care access loop.

The researchers recommended primary care providers at least send patient portal or outreach messages to patients completing FIT outlining the benefits of following up positive results with a colonoscopy screening.

These findings align with previous studies about closing patient care gaps.

A December 2021 study from the Mayo Clinic showed that shared decision-making helped improve rates of preventive screenings like screenings for colorectal cancer.

This study did have some differences from the Dutch one outlined above. The Mayo Clinic researchers looked at patient access to any type of colorectal cancer screening, not just follow-up after a positive FIT.

Nevertheless, it did underscore the role that collaborative decision-making, plus accounting for patient care needs, can play in patient care access.

The researchers operated under the mindset that the most effective kind of colorectal cancer screening is the one the patient will actually access, despite most agreeing that colonoscopy is the gold standard for those at average risk for cancer.

A survey of just under 800 primary care providers and about 150 gastroenterologists (GIs) showed that both primary care providers and GIs were more likely to refer patients to a noninvasive screening option, like a stool test, if the patient was not able to undergo invasive procedures.

Both specialists also favored noninvasive options for patients who said they could not take time off work for a colonoscopy, who did not think they needed a screening, or who refused other screening options.

"These findings suggest that primary care clinicians recognize the need to tailor their colorectal cancer screening recommendations to the preferences of their patients, especially with the emergence of new, less invasive options," Paul Limburg, MD, a gastroenterologist at Mayo Clinic and the study’s senior author, publicly stated.

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