New Hampshire Colorectal Cancer Screening Program (NHCRCSP) Patient Navigation Intervention

Each year in the United States, approximately 50,000 people die from colorectal cancer (CRC), the second-leading cause of cancer-related deaths. CRC screening can detect colorectal cancer at an early stage to maximize the potential for treatment to be effective. Further, the detection and removal of polyps can prevent colorectal cancer from developing. The U.S. Preventive Services Task Force recommends regular screening beginning at age 50 and continuing until age 75 using high-sensitivity fecal occult blood testing (FOBT), sigmoidoscopy, or colonoscopy. Despite these recommendations, only 65% of adults are up to date with colorectal cancer screening. Moreover, people without insurance and those at lower income levels are less likely to access CRC screening than insured and higher-income individuals are. Interventions designed to promote colorectal cancer screening among low-income, uninsured, and/or underinsured populations are needed.

The New Hampshire Colorectal Cancer Screening Program (NHCRCSP) Patient Navigation Intervention is designed to increase quality colorectal cancer screening among men and women aged 50 to 64 years who are low-income, uninsured, and/or underinsured patients across the state of New Hampshire. Registered nurses who serve as patient navigators deliver the intervention by phone to educate and support patients throughout the entire screening process. Quality screening includes informing patients that they are due for screening or surveillance colonoscopy and ensuring patients keep their appointments, have good preparation for colonoscopy, receive test results, and receive recommendations for follow-up screening that are consistent with national screening guidelines.

After a patient is enrolled, the patient navigator delivers the intervention by covering six topics via protocol- specific telephone contacts through a series of calls over several days to a few weeks, with the number and length of calls depending on patient needs. Calls are guided by a structured protocol. The specific topics are listed below. During the calls, the navigator:

-- Seeks the patient's agreement to undergo colonoscopy, confirms appointment scheduling, establishes rapport, and assesses barriers

 

-- Reviews bowel preparation instructions and directions for how and where to obtain the bowel preparation, addressing barriers and confirming transportation and patient escort plans (5-7 days before colonoscopy)

 

-- Reviews bowel preparation instructions in specific detail and addresses any challenges and remaining barriers (1-2 days before colonoscopy)

 

-- Confirms the appointment details (including location and transportation), discusses bowel preparation progress, and answers any remaining questions (the day before colonoscopy)

 

-- Evaluates the colonoscopy experience and provides any necessary support (shortly after the procedure)

 

-- Confirms the patient received and understands the results and rescreening recommendation provided by the endoscopist (ideally within 2-4 weeks after colonoscopy)

The patient navigator can also email the patient to provide appointment information and details. All patient information (e.g., patient medical history and tests, referrals, recorded details of each call) is tracked in a secure data system.

Within a few weeks after the exam, the patient navigator reviews pathology results with the medical director and assesses the endoscopist's follow-up recommendations against screening guidelines, with any discrepancies discussed with the endoscopist. If a patient is diagnosed with cancer, the navigator makes necessary arrangements to ensure the patient is able to successfully access cancer treatment. Patients can contact their navigator if they have questions, screening problems, or concerns.

This program uses intervention approaches recommended by the Community Preventive Services Task Force: patient navigation services to increase cancer screening and advance health equity (Colorectal Cancer Screening - Colonoscopy Alone) and multicomponent interventions (Colorectal Cancer Screening - Colonoscopy Alone). This program also uses the following intervention approaches for which the Community Preventive Services Task Force finds insufficient evidence: small media interventions (Colorectal Cancer Screening - Colonoscopy Alone), one-on-one education interventions (Colorectal Cancer Screening - Colonoscopy Alone) and interventions to reduce structural barriers for clients (Colorectal Cancer Screening - Colonoscopy Alone). Insufficient evidence means the available studies do not provide sufficient evidence to determine if the intervention is or is not effective. This does not mean that the intervention does not work. It means that additional research is needed to determine whether the intervention is effective.

-- Approximately 120 minutes per patient to deliver the six-topic protocol by phone (including time spent during the call to discuss barriers and ways to overcome them).

 

-- Adequate time for assessing existing infrastructure and planning and managing the patient navigation intervention (e.g., identifying a person for medical oversight, hiring and training staff, developing partnerships, setting up the data system). The amount of time will vary depending on the current systems in place.

 

The intervention was designed for low-income, uninsured, and/or underinsured adults aged 50 and older. Additional populations may benefit from patient navigation services.

The intervention is designed to be implemented in home and clinical settings that are in rural, suburban, and urban communities.

Required resources to implement the program include the following:
-- Replication Manual October 2016
-- Colorectal Cancer Screening Brochure
-- Information and Preparation Instructions for Your Colonoscopy
-- Colonoscopy Referral Form
-- Enrollment Packet
-- Provider Pocket Card
-- Patient Thank You Card
-- Colonoscopy Prep Tips Video

For costs associated with this program, please contact the developers, Lynn Butterly and Joanne Gersten. (See products page on the EBCCP website for developer contact information.)

A retrospective non-equivalent comparison group research design evaluated the impact of the intervention on completion of colonoscopy at 1 of 12 endoscopy centers in which the intervention was implemented across the state of New Hampshire. Outcomes data for comparison was obtained through the program database (for navigated patients) as well as medical records in existing databases (for non-navigated patients). The clinical outcomes of patients receiving the patient navigation intervention were compared with those of patients receiving usual care, which consisted of phone calls from varying individuals on bowel preparation, clinic policies, and review of medical details.

Since the study was retrospective, patients were not physically recruited, nor was there a selection process that pre-determined group assignment. Patient data were abstracted from medical records for the single clinic for all patients who were aged 50 to 64, had an income level of less than 250% of the federal poverty level, were uninsured, were scheduled for and notified of the colonoscopy test date between July 1, 2012, and September 30, 2013, were scheduled for a screening or surveillance colonoscopy, and had no diagnosis of CRC from a completed test.

Among study participants (n=131 in the intervention group, n=75 in the usual care group), 84% were 50-59 and 16% were 60-64; 57% were female and 43% were male; and 67% were White, 6% were Black/African American, 15% were Asian, 1% were "other race," and 11% refused to answer or did not know. Additionally, 79% were non-Hispanic, 17% were Hispanic, and 5% refused to answer or did not know. The primary language was English (67%), followed by Spanish and "other" (each 17%), and 28% of participants needed an interpreter. At baseline, there were significant differences between the intervention group and usual care group observed for gender, race, ethnicity, primary language, and interpreter needed, as well as rates of previous screening and smoking.

Data for patients in the intervention group were extracted from the NHCRCSP database system, Catalyst, a cloud-based software system. Data for patients in the usual care group were extracted from electronic medical records using a structured abstraction form that was directly linked to an Excel spreadsheet. The primary study outcome was colonoscopy completion within 12 months of receiving confirmation of the scheduled test date. (Patients who missed a colonoscopy appointment or had an incomplete colonoscopy due to inadequate preparation were tracked and counted as having a complete colonoscopy if the screening test were subsequently conducted.) Secondary outcomes were adequate bowel preparation quality, missed appointments/no-shows, cancellation less than 24 hours before the appointment, results communicated to the primary care physician, and consistency between the endoscopist's recommended re-screening or surveillance interval and clinical CRC guidelines. The Fisher exact test of independence was used to measure the outcomes, and prevalence odd ratios were also calculated.

 

Patients in the intervention group had a higher rate of colonoscopy screening compared with those in the usual care group (96.2% vs. 69.3%; p<.001).

 

Additional Findings

• The intervention group, in comparison with the usual care group, had significantly better rates of the following: adequate bowel preparation quality (97.6% vs. 87.5%; p=.010), missed appointments (0.0% vs. 15.6%; p<.001), cancellations less than 24 hours before appointment (0.8% vs. 16.0%; p<.001), results communicated to the primary care provider (100.0% vs. 48.1%; p<.001), and final recommended rescreening interval consistent with clinical guidelines (100.0% vs. 82.4%; p<.001).