American Medical Group Association, Alexandria, Virginia.
Exact Sciences, Madison, Wisconsin.
JAMA Netw Open. 2023 Jan 3;6(1):e2251384. doi: 10.1001/jamanetworkopen.2022.51384.
Noninvasive stool-based screening tests (SBTs) are effective alternatives to colonoscopy. However, a positive SBT result requires timely follow-up colonoscopy (FU-CY) to complete the colorectal cancer screening paradigm.
To evaluate FU-CY rates after a positive SBT result and to assess the association of the early COVID-19 pandemic with FU-CY rates.
DESIGN, SETTING, AND PARTICIPANTS: This mixed-methods cohort study included retrospective analysis of deidentified administrative claims and electronic health records data between June 1, 2015, and June 30, 2021, from the Optum Labs Data Warehouse and qualitative, semistructured interviews with clinicians from 5 health care organizations (HCOs). The study population included data from average-risk primary care patients aged 50 to 75 years with a positive SBT result between January 1, 2017, and June 30, 2020, at 39 HCOs.
The primary outcome was the FU-CY rate within 1 year of a positive SBT result according to patient age, sex, race, ethnicity, insurance type, Charlson Comorbidity Index (CCI), and prior SBT use.
This cohort study included 32 769 individuals (16 929 [51.7%] female; mean [SD] age, 63.1 [7.1] years; 2092 [6.4%] of Black and 28 832 [88.0%] of White race; and 825 [2.5%] of Hispanic ethnicity). The FU-CY rates were 43.3% within 90 days of the positive SBT result, 51.4% within 180 days, and 56.1% within 360 days (n = 32 769). In interviews, clinicians were uniformly surprised by the low FU-CY rates. Rates varied by race, ethnicity, insurance type, presence of comorbidities, and SBT used. In the Cox proportional hazards regression model, the strongest positive association was with multitarget stool DNA use (hazard ratio, 1.63 [95% CI, 1.57-1.68] relative to fecal immunochemical tests; P < .001), and the strongest negative association was with the presence of comorbidities (hazard ratio, 0.64 [95% CI, 0.59-0.71] for a CCI of >4 relative to 0; P < .001). The early COVID-19 pandemic was associated with lower FU-CY rates.
This study found that FU-CY rates after a positive SBT result for colorectal cancer screening were low among an average-risk population, with the median HCO achieving a 53.4% FU-CY rate within 1 year. Socioeconomic factors and the COVID-19 pandemic were associated with lower FU-CY rates, presenting opportunities for targeted intervention by clinicians and health care systems.
非侵入性粪便检测（SBT）是结肠镜检查的有效替代方法。然而，SBT 阳性结果需要及时进行后续结肠镜检查（FU-CY）以完成结直肠癌筛查模式。
评估 SBT 阳性后的 FU-CY 率，并评估早期 COVID-19 大流行对 FU-CY 率的影响。
设计、地点和参与者：本混合方法队列研究包括对 2015 年 6 月 1 日至 2021 年 6 月 30 日期间来自 Optum Labs 数据仓库的匿名行政索赔和电子健康记录数据的回顾性分析，以及来自 5 个医疗机构（HCO）的临床医生的半结构化定性访谈。研究人群包括平均风险的初级保健患者，年龄在 50 至 75 岁之间，在 39 个 HCO 中于 2017 年 1 月 1 日至 2020 年 6 月 30 日期间进行了 SBT 阳性。
主要结果是根据患者年龄、性别、种族、族裔、保险类型、Charlson 合并症指数（CCI）和先前的 SBT 使用情况，在 SBT 阳性后 1 年内 FU-CY 率。
本队列研究包括 32769 人（女性 16929 人[51.7%]；平均[SD]年龄 63.1[7.1]岁；黑人 2092 人[6.4%]，白人 28832 人[88.0%]；西班牙裔 825 人[2.5%]）。SBT 阳性后 90 天内 FU-CY 率为 43.3%，180 天内为 51.4%，360 天内为 56.1%（n=32769）。在访谈中，临床医生对低 FU-CY 率感到非常惊讶。各率因种族、族裔、保险类型、合并症和 SBT 使用情况而异。在 Cox 比例风险回归模型中，与粪便免疫化学检测相比，最强的阳性关联是多靶粪便 DNA 使用（风险比，1.63[95%CI，1.57-1.68]；P<0.001），而最强的阴性关联是合并症的存在（风险比，0.64[95%CI，0.59-0.71]，CCI>4 与 0 相比；P<0.001）。早期 COVID-19 大流行与 FU-CY 率较低有关。
本研究发现，在平均风险人群中，结直肠癌筛查 SBT 阳性后 FU-CY 率较低，中位数 HCO 在 1 年内达到 53.4%的 FU-CY 率。社会经济因素和 COVID-19 大流行与 FU-CY 率降低有关，为临床医生和医疗保健系统提供了有针对性干预的机会。
