a) Project Background/Rationale. Fecal Occult Blood Testing (FOBT), the primary screening mode employed by the Veterans Health Administration (VA), can be a highly efficacious colorectal cancer screening method if positive results are followed by complete diagnostic evaluation (CDE). However, significant gaps in receipt of CDE have been identified in the VA. The information this study will provide on the patterns and determinants of time to CDE (i.e., diagnostic colonoscopy) following a positive colorectal cancer (CRC) screening result will help identify the most fruitful targets for future CRC diagnosis quality improvement efforts. b) Project Objectives. Primary objectives are to: (1) Estimate the effects of organizational structures, clinic processes, and intermediate outcomes on CDE rates;(2) Develop recommendations regarding which CDE barriers to target in future improvement efforts;and (3) Estimate the relative contribution to average CDE wait times of: patient refusal;outside colonoscopies;and potential inappropriate utilization of colonoscopy. Secondary objectives include: assessing facility and patient level variation in the patterns and determinants of CDE rates;estimating the relative contribution to CDE rates of: (i) time between FOBT positive results and CDE scheduling (front-end delays), and (ii) time between CDE scheduling and completion (back-end delays); and assessing the validity of perceived barriers to CDE reported by facilities. c) Project Methods. This three-year observational study will: (1) conduct a web-based survey of 137 VA facilities to assess current CRC diagnosis practices and perceived barriers to improvement, (2) randomly select 38 facilities responding to this survey, and then (3) extract from each selected facility all FOBT positive (FOBT+) cases occurring within one year prior and six months after the survey. For each FOBT+ case we will extract from VA administrative records dates for: FOBT+ result;when a colonoscopy appointment was scheduled, cancelled, and completed (if applicable);as well as patient demographic and health characteristics. The primary analyses will: (1) estimate the association between time to CDE and measures of organizational structures, clinical processes, and intermediate outcomes using hazard regression techniques;(2) use a predictive model based on these results to develop facility-specific recommendations regarding which CDE barriers to target in future improvement efforts;and (3) use survival analysis techniques to estimate the relative contribution to CDE rate estimates of: patient refusal, outside colonoscopies;and potential inappropriate utilization of colonoscopy. Additional analyses will estimate the relative contribution of front and back end delays to CDE wait times;assess the validity of self-reported facility data on barriers to improvement;and determine whether specific patient subgroups are more vulnerable to delays in obtaining CDE.
This project will provide information on the patterns and determinants of time to complete diagnostic evaluation (i.e., diagnostic colonoscopy) following a positive colorectal cancer (CRC) screening result that will help identify the most fruitful targets for future CRC diagnosis quality improvement efforts. Findings regarding the extent of inappropriate utilization of colonoscopy can be used to refine the CRC follow-up performance measures currently under development.