Project Summary Follow-up colonoscopy after abnormal stool-based colorectal cancer screening (e.g., fecal immunochemical test (FIT)) results in early detection of colorectal cancer (CRC), prevention of CRC, and reduction in CRC-mortality. FIT is a commonly utilized screening test that can be performed at home, is inexpensive, scalable, and often adopted in health systems where colonoscopy resources are scarce. Despite evidence that timely colonoscopy is necessary after an abnormal FIT result, completion colonoscopy occurs in less than 50% of patients at 6 months and varies significantly by clinic and health systems. In addition to understanding the meaning of an abnormal FIT, three care transitions must occur smoothly for the patient: colonoscopy referral, scheduling, and attendance. However, multilevel factors influence missed follow-up, and multilevel solutions are needed along the care continuum to address clinic-, provider-, and patient-level factors that impair or delay colonoscopy completion. IMProving Adherence to Colonoscopy through Teams and Technology (IMPACTT), proposes to close gaps and reduce disparities in CRC screening by improving completion of diagnostic colonoscopy following abnormal FIT in vulnerable populations using a multilevel approach consisting of interventions at the clinic-, provider- and patient-level. The specific aims are 1) to evaluate the effect of a clinic-level intervention targeting primary care providers and staff to adopt “best practices” to support colonoscopy completion in patients with abnormal FIT results, 2) to determine the effect of a patient-level technology intervention with enhanced instructions and navigation for patients with abnormal FIT to complete a diagnostic colonoscopy, and 3) to explore the multilevel implementation factors contributing to intervention outcomes using mixed methods. IMPACTT is situated in a publicly-funded, urban safety-net health system that cares for diverse, low-income patients with a high prevalence of limited health literacy and English proficiency. In order to develop solutions that work for vulnerable patients that are at particular risk to incomplete follow-up, interventions must be conducted in the settings that serve them. In addition, given the complexity of patient health behaviors and the multi-step process of colonoscopy completion, scalable interventions are needed. This proposal is feasible in this health system because 1) FIT screening is standard practice for CRC screening, 2) the system’s 12 primary care clinics is integrated with one gastroenterology practice, and 3) primary care and specialty care share an electronic health record and consultation system. These characteristics offer an infrastructure for implementation and evaluation, facilitated by effective care coordination and communication. IMPACTT is positioned to develop a multilevel intervention to improve CRC follow-up for vulnerable populations, which holds the potential to reduce health disparities in other health systems as well as lay the foundation to address other health conditions and behaviors.

Project Narrative Complete and timely colonoscopy after an abnormal stool-based colorectal cancer screening test results in early detection, cancer prevention, and reduction in mortality, but follow-up in safety-net health systems occurs in less than 50% at 6 months. The proposal will implement multi-level approach consisting of a stepped-wedge clinic- level intervention of team-based best practices co-developed with primary and specialty care, a patient-level technology intervention to provide enhanced instructions and navigation to complete diagnostic colonoscopy, and a mixed methods evaluation to explore multi-level factors contributing to intervention outcomes. Developing a solution to this high-risk and diverse population has the potential to translate to other health systems, support patient self-management, and address other patient conditions.