Improving Follow-up Recommendations After a Colonoscopy for Colorectal Cancer Screening

1. Background and Significance

Routine cancer screening reduces cancer-specific mortality and is recommended by the US Preventive Services Task Force (USPSTF) and other national guidelines for breast, cervical, colorectal, and lung cancer. Many research and quality improvement studies focus on the timely completion of cancer screening as a discrete event, but it is a process that requires repetition of screening over the life course and when surveillance is required because of prior abnormalities. Though much progress has been made in advancing the use of cancer screening, timely screening and surveillance of any abnormal screening result is critical to realizing the maximal benefits of screening but often is not achieved. These challenges are especially true for colorectal cancer (CRC) screening -the second leading cause of cancer-related deaths in the US.

Responsibility for cancer screening and follow-up falls to the ordering provider, typically a primary care practitioner (PCP). Though electronic health records (EHRs) may have reminders for routine screening results with an option to manually edit modifiers for short interval screening, few PCPs or their practices have integrated management systems to track abnormalities and manage follow-up.

The transition from routine screening to follow-up surveillance colonoscopy (FSC) includes responsibility for both PCPs and gastrointestinal (GI) specialists. Failure to receive an appropriate FSC undermines the benefits of screening, violates the trust that patients place in their providers and health systems, and increases medicolegal risk.

This proposal seeks to address two key components of ensuring appropriate FSC needed for any systematic safety program - improving the recommended follow-up interval that is based upon current guidelines and ensuring that the follow-up interval specified in the EHR is kept up to date using the most recent colonoscopy results. The current system requires GI specialists to perform these tasks without any decision support. This proposal seeks to automate updating the follow-up interval specified in the EHR after a colonoscopy and to develop the framework of agreement among GI specialists for determining a follow-up interval based upon all patient factors. 2. General Description of Study Design Working with MGB digital health, the investigators will implement a new colonoscopy results letter with a structured field for recommended interval follow-up that automatically updates the Epic EHR reminder used by patients and PCPs. The investigators will then conduct a trial of MGH primary care patients aged 45-75 undergoing screening and surveillance colonoscopy and randomize the performing GI specialist to use the new protocol to set the FSC interval (intervention) or to usual care (control.) 3. Subject Selection Subjects are GI specialists who perform colonoscopies for colorectal cancer screening at MGH. Patients of participating GI specialists meeting the following criteria will be included. Patients seen in an MGH-affiliated primary care practice who are English or Spanish-speaking patients aged 45-75 and have had a colonoscopy at MGH. Patients undergoing a diagnostic colonoscopy, who have a history of inflammatory bowel disease, a hereditary colon condition, or already have a history of colon cancer will be excluded.