Andrew Wangf HW1

Andrew Wangf HW1

by Andrew -

Colorectal cancer (CRC) is the second leading cause of cancer deaths in the United States and is preventable through screening methods such as fecal immunochemical test (FIT) with a colonoscopy follow-up. Despite evidence that screening is effective in reducing CRC related mortality, improperly completed FITs in the safety-net health system and lost to follow-up is  problematic.

Within safety-net health systems, FIT has been a preferred option for population-level screening. However, low-income, recent immigrants, and non-English speaking populations who often receive care from safety-net health systems may experience difficulty comprehending and completing FIT using word-based and English instructions, and have difficulties adhering to follow-up colonoscopy instructions. Studies have demonstrated the usefulness of pictorial instructions, reminder phone calls, and specifically tailored educational videos in complementing routine examinations.  

Currently, I am interested in examining the nature behind mishandled FIT specimens and the reasons for lost to follow-up after an abnormal FIT result. I would like to conduct a randomized trial to increase FIT participation, which offers an opportunity to examine the impact of outreach in the form of the implementation of low literacy instructions (instead of text based) and reminder phone calls on the rate of mishandled FIT samples in a large integrated safety-net health system. An additional followup study would be the removal or addition of text based instruction for adequate colonoscopy preparation in exchange for the implementation of educational videos (tailored to language and racial/ethnicity) in an effort to increase colonoscopy completion following an abnormal FIT.  


Re: Andrew Wangf HW1

by Richard Wang -

Hi Andrew -

You outline an interesting implementation gap: the gap between abnormal FIT result and appropriate colonoscopic follow-up. Based on your review of the literature, about how big is that gap? In other words, what proportion of patients with abnormal FIT testing fail to follow through with colonoscopy?

Otherwise, I'm not entirely sure what you mean by mishandled FIT specimens--this could be clarified.

Great work!

Ricky Wang (no relation)

Re: Andrew Wangf HW1

by Andrew -

Hi Ricky, 

Thank you for your generous comments. Within the safety-net systems, I would say somewhere around ~20-30% of FIT are "mishandled" or inappropriately complete (text based instruction are akin to a take home pregnancy test)  and ~25-30% are lost to follow up after an abnormal mail returned FIT results. 

For the former issues, I suspect there is an educational, cultural attitude and to some degree SES related to proper FIT completion. 

For the latter issue, I suspect there is an educational and SES related to colonoscopy follow up. The proportion is quite high as there could be a lost in communication after FIT results from either ends, non adherence to colonoscopy preparation causing reschedule leading to increased proportion of no shows, and scheduling conflicts between the providers and patients.

Thank you! 

Andrew 

Re: Andrew Wangf HW1

by Todd -


Hey Andrew,

What a great project! 

To establish the magnitude of the issue you may want to include baseline data on colon cancer occurance in your population(s) of interest.

Also, you may be interested to know there are several phone Apps that are tailored to screening colonoscopy appointment instructions; however, their use may be targeted to a different population. 

I recall there is a screening colonoscopy no-show rate of ~15% nationally which certainly leads to wasted resources although you appear to be focusing on the FIT.

Also, in case you haven’t seen it, there is a NEJM article on CRC screening methods which you may find useful.

N Engl J Med 2017; 376:149-156.

Thanks for sharing!

-Todd

Re: Andrew Wangf HW1

by Andrew -

Hi Todd,

Thank you for your generous comments and for providing the article. The specific population I am interested in is the health safety-network systems under the SFDPH. The lost to followup in my population of interest seem to be higher as I suspect its due to the initial screening was based off a mail returned FIT. This may increase the likelihood lost communications, inadequate colonoscopy preparations and scheduling conflict as opposed to directly receiving the info from the clinic. However, as you suggested, a better approach is surely needed. 

The phone apps are a wonderful resourceful tool. I will look into this as another method. I think the struggle will definitely be defining what technologies does the sample possess and may also comprehend. 

Thank you,

Andrew 

Re: Andrew Wangf HW1

by Rashed -

Hey Andrew, 

Very interesting project, and certainly an alarming gap you have mentioned. In your first paragraph, you have mentioned a critical point regarding screening--while screening is shown to be effective, improper completions of FITs is troublesome. This is unfortunately a very common case across empirically supported interventions/assessments especially when dealing with underprivileged or minority populations. 

I am not sure if you have looked into this, but I was curious about whether stigma has to do with improper completions--do you think immigrants/non-English speaking populations may feel anxious during such assessment? I wonder if the studies you alluded to looked into that. If it is significant, I think addressing this matter is another potentially strong IS project. 

As I mentioned, I think your project is very interesting and important to address this gap. This made me think about the other course we are taking--community engagement research. Who are your community partners? How did you decide on low literacy instructions (instead of text based) and reminder phone calls--were patients asked about their preferences?