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Colonoscopy Completion in a Large Safety Net Health Care System

2008; Elsevier BV; Volume: 6; Issue: 4 Linguagem: Inglês

10.1016/j.cgh.2007.12.003

1542-7714

Elina S. Kazarian, Fernando S. Carreira, Neil W. Toribara, Thomas D. Denberg,

Global Cancer Incidence and Screening

Background & Aims: Anecdotally, patients in safety net health care systems have difficulty completing screening and diagnostic colonoscopies, but this is poorly characterized. It is important to understand this phenomenon to improve low rates of colorectal cancer screening in vulnerable populations and to ensure that patients with signs and symptoms complete medically indicated colonoscopic evaluations. Methods: We performed a 6-month retrospective review of outpatient endoscopy laboratory scheduling and procedure logs and electronic medical records at Denver Health Medical Center (DHMC), a large safety net health care system, to describe rates and sociodemographic predictors of colonoscopy nonattendance and inadequate (fair/poor) bowel preparation. Predictor variables included patient age, gender, race/ethnicity, procedure indication, and insurance type. Results: The nonattendance rate was 41.7% for all scheduled outpatient colonoscopies without difference between screening and diagnostic procedures. Consistent with non–safety net systems, the rate of inadequate bowel preparation was 30.2%; however, the rate of poor bowel preparation that absolutely precluded an exam was 9.9%. Correctional care patients had markedly higher rates of nonattendance and inadequate bowel preparation compared with other groups. Conclusions: A very large proportion of patients scheduled for colonoscopy in a large safety net health care system do not attend their procedures, and among those who do, there is a high rate of inadequate bowel preparation leading to incomplete and aborted evaluations. Interventions are needed to promote the more efficient use of a limited and expensive resource and to achieve higher rates of screening and medically indicated diagnostic colonoscopies in vulnerable patient populations. Background & Aims: Anecdotally, patients in safety net health care systems have difficulty completing screening and diagnostic colonoscopies, but this is poorly characterized. It is important to understand this phenomenon to improve low rates of colorectal cancer screening in vulnerable populations and to ensure that patients with signs and symptoms complete medically indicated colonoscopic evaluations. Methods: We performed a 6-month retrospective review of outpatient endoscopy laboratory scheduling and procedure logs and electronic medical records at Denver Health Medical Center (DHMC), a large safety net health care system, to describe rates and sociodemographic predictors of colonoscopy nonattendance and inadequate (fair/poor) bowel preparation. Predictor variables included patient age, gender, race/ethnicity, procedure indication, and insurance type. Results: The nonattendance rate was 41.7% for all scheduled outpatient colonoscopies without difference between screening and diagnostic procedures. Consistent with non–safety net systems, the rate of inadequate bowel preparation was 30.2%; however, the rate of poor bowel preparation that absolutely precluded an exam was 9.9%. Correctional care patients had markedly higher rates of nonattendance and inadequate bowel preparation compared with other groups. Conclusions: A very large proportion of patients scheduled for colonoscopy in a large safety net health care system do not attend their procedures, and among those who do, there is a high rate of inadequate bowel preparation leading to incomplete and aborted evaluations. Interventions are needed to promote the more efficient use of a limited and expensive resource and to achieve higher rates of screening and medically indicated diagnostic colonoscopies in vulnerable patient populations. See Editorial on page 377. See Editorial on page 377. Colorectal cancer screening is a high-impact, cost-effective service used by less than half of persons aged 50 and older.1Maciosek M.V. Solberg L.I. Coffield A.B. et al.Colorectal cancer screening: health impact and cost effectiveness.Am J Prev Med. 2006; 31: 80-89Abstract Full Text Full Text PDF PubMed Scopus (103) Google Scholar Among patients who are racial/ethnic minorities or socioeconomically disadvantaged, there is evidence that screening rates are substantially lower than in the general population.2Ananthakrishnan A.N. Schellhase K.G. Sparapani R.A. et al.Disparities in colon cancer screening in the Medicare population.Arch Intern Med. 2007; 167: 258-264Crossref PubMed Scopus (108) Google Scholar, 3Phillips K.A. Liang S.Y. Ladabaum U. et al.Trends in colonoscopy for colorectal cancer screening.Med Care. 2007; 45: 160-167Crossref PubMed Scopus (107) Google Scholar Although debated, colonoscopy might be the most cost-effective screening modality because it is usually required at only 10-year intervals and is both a diagnostic and therapeutic procedure.4Sonnenberg A. Delco F. Inadomi J.M. Cost-effectiveness of colonoscopy in screening for colorectal cancer.Ann Intern Med. 2000; 133: 573-584Crossref PubMed Scopus (440) Google Scholar In low income, racial/ethnic minority groups, colonoscopy might be especially advantageous because adherence tends to be poor for more frequently required alternatives such as stool cards and flexible sigmoidoscopy. One of the most important barriers to colorectal cancer screening is the absence of a medical provider recommendation.5Klabunde C.N. Vernon S.W. Nadel M.R. et al.Barriers to colorectal cancer screening: a comparison of reports from primary care physicians and average-risk adults.Med Care. 2005; 43: 939-944Crossref PubMed Scopus (257) Google Scholar Thus, when medical providers do refer patients for screening colonoscopy, it is important to facilitate the completion of this procedure. Separately, patients with signs and symptoms should also complete referrals for medically indicated diagnostic colonoscopies. Safety net health systems focus on delivering health care services to uninsured, Medicaid, and other vulnerable populations.6Lewin M. Altman S. The health care safety net in a time of fiscal pressures. National Academy Press, Washington, DC2000Google Scholar Poor and minority patients served by safety net health care systems often do not complete colonoscopies for which they have been referred and scheduled. In personal communication (endoscopy laboratory charge nurses: San Francisco General Hospital; Harborview Medical Center, Seattle; Cook County Hospital, Chicago; 2006), managers of endoscopy laboratories in several safety net health systems told us that their colonoscopy no-show rates are "very high." Although knowledgeable individuals have remarked on this phenomenon imprecisely and anecdotally, the problem of failed colonoscopies in safety net systems has not been systematically characterized. To encourage a formal approach to a problem whose origins and potential solutions are likely to have much in common across similar institutions, our objective was to identify rates and sociodemographic predictors of nonattendance and inadequate bowel preparation for all colonoscopy indications in our own large safety net system in Denver, Colorado. Consistent with prior studies in non–safety net health care systems, we anticipated that nonattendance rates in our institution would be significantly higher among younger patients, women, those with no/low-income insurance, and possibly those of black and Latino race/ethnicity than among older patients, men, those with Medicare or commercial health plans, and non-Latino whites.7Denberg T.D. Coombes J.M. Byers T.E. et al.Effect of a mailed brochure on appointment-keeping for screening colonoscopy: a randomized trial.Ann Intern Med. 2006; 145: 895-900Crossref PubMed Scopus (72) Google Scholar, 8Matthews B.A. Anderson R.C. Nattinger A.B. Colorectal cancer screening behavior and health insurance status (United States).Cancer Causes Control. 2005; 16: 735-742Crossref PubMed Scopus (54) Google Scholar, 9Turner B.J. Weiner M. Yang C. et al.Predicting adherence to colonoscopy or flexible sigmoidoscopy on the basis of physician appointment-keeping behavior.Ann Intern Med. 2004; 140: 528-532Crossref PubMed Scopus (46) Google Scholar Also, possibly because of patient motivation, we expected that nonattendance would be significantly higher among patients scheduled for screening and surveillance compared with diagnostic procedures.10Frew E. Wolstenholme J. Whynes D. Mass population screening for colorectal cancer: factors influencing subjects' choice of screening test.J Health Serv Res Policy. 2001; 6: 85-91Crossref PubMed Scopus (25) Google Scholar Little prior work has described correlates of inadequate bowel preparation. The study was carried out at Denver Health Medical Center (DHMC), a large community-based medical facility that serves more than 25% of Denver County residents. Fourteen percent of DHMC patients are black, and 54% are Latino. Approximately 65% of patients are below 185% of the federal poverty level, and uninsured patients account for 42% of all charges. DHMC also provides services for incarcerated patients in the City and County of Denver. Screening and surveillance colonoscopies at DHMC are facilitated through direct referrals ("open-access") by primary care providers in general internal medicine and family practice; virtually no patients are referred for colonoscopy from outside the system. Although fecal occult blood testing (FOBT) is used most frequently for screening purposes, patients might be referred for colonoscopy after they repeatedly do not return FOBT cards, if they require a concomitant diagnostic esophagogastroduodenoscopy (EGD), if they express a strong preference for colonoscopy, or if primary care providers prefer colonoscopy over alternatives. Flexible sigmoidoscopy and barium enema are seldom carried out within DHMC. Because colonoscopy, on the other hand, is commonly scheduled, requires the greatest amount of preparation, and is the de facto gold standard for screening and diagnostic purposes, we chose to focus solely on this procedure rather than on other modalities that have distinct barriers to completion. Almost all diagnostic colonoscopy referrals are also generated by primary care providers within the system, although these sometimes require a gastroenterologist consultation before colonoscopy is completed. After a gastroenterologist reviews the appropriateness of all colonoscopy referrals, these are forwarded to the endoscopy staff at DHMC, who schedule procedures after telephone contact with patients. Average wait time for nonurgent colonoscopy is approximately 6–8 weeks. Written reminders are not routinely sent to the patients; however, telephone reminders are attempted. At the time of referral, patients receive an instruction sheet (in English or Spanish, as appropriate) and a prescription for polyethylene glycol–based isosmotic peroral colonic lavage. The cost of this prescription is about $8.00 for most patients. For the vast majority of health plans, there is no co-payment for colonoscopy. Patients enrolled in the Colorado Indigent Care Program made the highest average co-payment amount of $40. We carried out a 6-month retrospective review (January–June 2006) of outpatient-based endoscopy scheduling and procedure logs and electronic medical records at DHMC. Patients who did not arrive or cancelled their scheduled procedure with less than 2 work days notice were coded as nonattenders. The quality of bowel preparations was based on the Global Preparation Assessment Scale as follows: excellent (clear, water-like stool), good (semi-clear, liquid stool), fair (colored liquid or semisolid stool amenable to suction), and poor (semisolid or solid stool, not amenable to suction).11Rostom A. Jolicoeur E. Validation of a new scale for the assessment of bowel preparation quality.Gastrointest Endosc. 2004; 59: 482-486Abstract Full Text Full Text PDF PubMed Scopus (350) Google Scholar A priori, poor and fair preparations were regarded as inadequate. This information was recorded as a required field during endoscopist report generation immediately after the conclusion of procedures (endoPRO software; Pentax Medical Company, Golden, CO). Patient sex, age, race/ethnicity, and insurance type were extracted from the electronic medical record. Rates of colonoscopy nonattendance and inadequate bowel preparation were based on the total number of patients for whom these categories applied divided by the number of patients scheduled for and undergoing colonoscopy, respectively, during the specified time period. Only a patient's first scheduled colonoscopy was considered in the analysis; procedures that were rescheduled or repeated were ignored. We used χ2 tests for categorical variables to characterize bivariate associations between nonattendance and inadequate bowel preparations, on the one hand, and patient sex, age, race/ethnicity, insurance type, and procedure indication, on the other. Multivariate odds ratios for nonattendance (versus attendance) were then calculated by retaining in a logistic regression model variables with a significance level of 0.25 or less in bivariate analysis.12Hosmer D.W. Lemeshow S. Applied logistic regression. Wiley, New York2000Crossref Google Scholar All statistical procedures were performed with SAS Version 9.1 (SAS Institute, Cary, NC). This study was approved by the Colorado Multiple Institutional Review Board after removal of personal health information. The final sample included 817 patients scheduled for outpatient colonoscopy. The overall nonattendance rate was 41.7% (Table 1). Less than 5% cancelled their procedures with less than 48 working hours notice; the vast majority simply did not arrive for the exam. Contrary to previously published observations, female sex, younger age, black and Latino race/ethnicity, and procedure indication were not associated with higher rates of nonattendance. However, attendance was significantly higher than average among patients referred for concomitant EGD and those with Denver Health Medical Plan (a health maintenance organization administered through Denver Health whose members are mainly composed of employees of Denver Health and Hospital Authority and the City and County of Denver and their dependents) and commercial insurance. Attendance was significantly lower than average among correctional care patients. Without difference by patient sex, age, race/ethnicity, payer, or procedure indication, the overall rate of poor bowel preparation was 9.9%, and of inadequate bowel preparation (poor/fair) it was 30.2%.Table 1Bivariate Associations and Multivariate Odds Ratios for Colonoscopy Nonattendance (DHMC, January–June, 2006)Patient characteristicNonattendance (%)P valueMultivariate odds ratio (95% confidence interval)aAdjusted for patient sex, procedure type, payer.Overall (n = 817)41.7Sex.16 Female (n = 424, 51.9%)39.4 Male (n = 393, 48.1%)44.3Age (y).60 <40 (n = 67, 8.2%)41.8 40–49 (n = 107, 13.1%)37.4 50–59 (n = 318, 38.9%)44.0 60–64 (n = 126, 15.4%)36.5 65–74 (n = 149, 18.1%)45.0 75+ (n = 50, 6.1%)40.0Race/ethnicity.96 Non-Latino white (n = 270, 33.0%)40.7 Latino (n = 341, 41.7%)41.1 Black (n = 149, 18.2%)39.6Payer<.001 Colorado Indigent Care (n = 254, 31.1%)43.3Reference Correctional care (n = 52, 6.4%)61.52.0 (1.1–3.3) Denver Health HMO (n = 77, 9.4%)31.20.5 (0.3–0.8) Medicare (n = 202, 24.7%)52.51.4 (1.0–2.0) Medicaid (n = 113, 13.8%)41.61.0 (0.6–1.4) Commercial (n = 68, 8.3%)5.90.1 (0.0–0.2)Procedure indication.36 Screening (n = 301, 36.8%)44.5 Surveillance (n = 110, 13.5%)41.9 Diagnostic (n = 405, 49.6%)39.5Procedure type<.001 Colonoscopy only (n = 570, 69.8%)46.3Reference Colonoscopy plus EGD (n = 247, 30.2%)31.20.5 (0.4–0.8)a Adjusted for patient sex, procedure type, payer. Open table in a new tab Colonoscopy nonattendance was extremely high in almost all patient groups within a large safety net system. In addition, although 30.2% of patients who attended their appointments had an inadequate bowel preparation, consistent with a rate quoted in a recent meta-analysis of non–safety net systems,13Tan J.J. Tjandra J.J. Which is the optimal bowel preparation for colonoscopy: a meta-analysis.Colorectal Dis. 2006; 8: 247-258Crossref PubMed Scopus (168) Google Scholar the rate of poor (as opposed to fair) quality preparation was 9.9%, which guarantees that at least 1 in 10 patients could not complete any meaningful portion of an exam. Thus, when poor bowel preparation is considered concurrently with nonattendance, at least 51.6% (ie, more than half) of patients failed to successfully complete a procedure for which a significant amount of administrative processing had taken place and clinical resources had been set aside. Rates of about 20% have been described for colonoscopy nonattendance for follow-up of positive FOBT in a Veterans Affairs setting 14Fisher D.A. Jeffreys A. Coffman C.J. et al.Barriers to full colon evaluation for a positive fecal occult blood test.Cancer Epidemiol Biomarkers Prev. 2006; 15: 1232-1235Crossref PubMed Scopus (87) Google Scholar and less than 5% for all open-access indications at both the University of Colorado Hospital (personal communication, GI/Endoscopy manager; June 2007) and Mayo Clinic, Scottsdale.15Gurudu S.R. Fry L.C. Fleischer D.E. et al.Factors contributing to patient nonattendance at open-access endoscopy.Dig Dis Sci. 2006; 51: 1942-1945Crossref PubMed Scopus (25) Google Scholar The colonoscopy nonattendance rate of 41.7% at Denver Health is much higher than has been described for patients in non–safety net systems in the United States, although it is comparable to a rate of 38.1% recently described at the University of Pennsylvania, an academic system that serves large numbers of poor and minority patients.9Turner B.J. Weiner M. Yang C. et al.Predicting adherence to colonoscopy or flexible sigmoidoscopy on the basis of physician appointment-keeping behavior.Ann Intern Med. 2004; 140: 528-532Crossref PubMed Scopus (46) Google Scholar Safety net patients might experience barriers to completing colonoscopy that are especially powerful. Indeed, these barriers might obviate the types of differences across patient subgroups (eg, age, sex) that have been described in other kinds of settings. For example, the nonattendance rate of Medicare beneficiaries was 52.5%, even though colonoscopy is a fully covered benefit for both screening and diagnostic purposes. Also, there was no difference in attendance between groups referred for diagnostic as opposed to screening/surveillance procedures, even though patient interest and motivation might be expected to be higher in the former group. Undoubtedly, an important barrier to colonoscopy completion at Denver Health is a protracted time interval between referrals and procedures (an average of 48–64 days), possibly contributing to patient forgetfulness and loss of motivation.16Denberg T.D. Melhado T.V. Coombes J.M. et al.Predictors of nonadherence to screening colonoscopy.J Gen Intern Med. 2005; 20: 989-995Crossref PubMed Scopus (217) Google Scholar In addition, because safety net patients are likely to have lower than average levels of formal education and English proficiency, they might have particular difficulty understanding instructions, greater fears about pain, lack of perceived risk, misunderstandings about preventive and diagnostic procedures, and more concerns about modesty.16Denberg T.D. Melhado T.V. Coombes J.M. et al.Predictors of nonadherence to screening colonoscopy.J Gen Intern Med. 2005; 20: 989-995Crossref PubMed Scopus (217) Google Scholar, 17O'Malley A.S. Beaton E. Yabroff K.R. et al.Patient and provider barriers to colorectal cancer screening in the primary care safety-net.Prev Med. 2004; 39: 56-63Crossref PubMed Scopus (127) Google Scholar, 18Denberg T.D. Wong S. Beattie A. Women's misconceptions about cancer screening: implications for informed decision-making.Patient Educ Couns. 2005; 57: 280-285Abstract Full Text Full Text PDF PubMed Scopus (45) Google Scholar Additional factors might include high levels of comorbid illness, transportation difficulties, less flexibility arranging time off from work or childcare, and impermanent residence and telephone contact information. Interventions at multiple levels of the health care system are needed to ameliorate high rates of colonoscopy nonattendance and inadequate bowel preparation. These should include more comprehensive, attractively packaged informational materials around the time of referral.19Abuksis G. Mor M. Segal N. et al.A patient education program is cost-effective for preventing failure of endoscopic procedures in a gastroenterology department.Am J Gastroenterol. 2001; 96: 1786-1790Crossref PubMed Google Scholar Mail and phone reminders might also have a modestly beneficial effect.7Denberg T.D. Coombes J.M. Byers T.E. et al.Effect of a mailed brochure on appointment-keeping for screening colonoscopy: a randomized trial.Ann Intern Med. 2006; 145: 895-900Crossref PubMed Scopus (72) Google Scholar, 20Vogt T.M. Glass A. Glasgow R.E. et al.The safety net: a cost-effective approach to improving breast and cervical cancer screening.J Womens Health (Larchmt). 2003; 12: 789-798Crossref PubMed Scopus (44) Google Scholar, 21Adams L.A. Pawlik J. Forbes G.M. Nonattendance at outpatient endoscopy.Endoscopy. 2004; 36: 402-404Crossref PubMed Scopus (60) Google Scholar In our experience, however, we were able to reach fewer than an estimated 40% of safety net patients by phone during daytime working hours even after 2 or 3 attempts. Accordingly, it might be useful to outsource or employ additional staff to make reminder calls after hours, a strategy we have not yet attempted. Preprocedure clinics that provide patients with education about the bowel preparation and reinforce the reasons for colonoscopy might also improve nonattendance rates and the quality of the preparation, but this has not been studied in depth. Although one article reported a dramatic improvement in colonoscopy attendance through the use of a preprocedure clinic, this was the result of rescinding colonoscopy appointments for patients who failed to attend the clinic.22Tibble J.A. Forgacs I. Bjarnason I. et al.The effects of a preassessment clinic on nonattendance rates for day-case colonoscopy.Endoscopy. 2000; 32: 963-965Crossref PubMed Scopus (19) Google Scholar In safety net settings, it seems likely that requiring patients to participate in preprocedure clinics would be more of an obstacle than an advantage for improving rates of colonoscopy attendance, although it might help to improve the quality of the bowel preparation and the ability to complete adequate procedures. Regardless, financing arrangements for such clinics would need to be devised. For instance, although Medicare and other payers usually reimburse for diagnostic preprocedure assessments, they do not do so for screening procedures.23Narramore L. Wiersema M.J. Mergener K. et al.Frequently asked coding questions.Gastrointest Endosc Clin N Am. 2006; 16: 789-799Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar Shorter wait times to procedures might be achieved by reducing the number of colonoscopy referrals through the more effective utilization of FOBT for cancer screening and appropriate intervals for adenoma surveillance.24Mysliwiec P.A. Brown M.L. Klabunde C.N. et al.Are physicians doing too much colonoscopy? a national survey of colorectal surveillance after polypectomy.Ann Intern Med. 2004; 141: 264-271Crossref PubMed Scopus (282) Google Scholar Stratifying patients' likelihood of nonattendance, perhaps by reference to their frequency of nonattendance at other types of clinic visits,9Turner B.J. Weiner M. Yang C. et al.Predicting adherence to colonoscopy or flexible sigmoidoscopy on the basis of physician appointment-keeping behavior.Ann Intern Med. 2004; 140: 528-532Crossref PubMed Scopus (46) Google Scholar might allow for the judicious overbooking of colonoscopy slots for patients at very high risk of nonattendance. With regard to strategies for improving the quality of colonic preparation, lower-volume sodium phosphate alternatives to polyethylene glycol are an option for most patients.13Tan J.J. Tjandra J.J. Which is the optimal bowel preparation for colonoscopy: a meta-analysis.Colorectal Dis. 2006; 8: 247-258Crossref PubMed Scopus (168) Google Scholar A minority of patients in our setting made a $40 co-payment for colonoscopy, an amount that might be prohibitively large for this population. Indeed, a trip to the pharmacy and an $8 payment to procure the bowel lavage could also be a substantial barrier for some patients. It is unclear, however, whether omitting all co-payments and charges or requiring these well in advance of procedures would have a beneficial or detrimental effect on receipt of colonoscopy. Patient navigators are nonclinical members of the community who have personal experience with the health care system and can help guide patients through the process of arranging, preparing for, and completing medical services. Because the rationale and required steps for completing colonoscopy are complex, patient navigators might be particularly helpful. Programs that have used patient navigators for this purpose have been very successful in minority community health centers and public hospitals in New York City and elsewhere.25Cancer Prevention and Control Program Bureau of Chronic Disease Prevention and ControlNew York City Department of Health and Mental HygieneNew York Citywide Colon Cancer Control CoalitionA practical guide to increasing screening colonoscopy: proven methods for health care facilities to prevent colorectal cancer deaths.http://www.nyc.gov/html/doh/downloads/pdf/cancer/cancer-colonoscopy-guide.pdfGoogle Scholar, 26Jandorf L. Gutierrez Y. Lopez J. et al.Use of a patient navigator to increase colorectal cancer screening in an urban neighborhood health clinic.J Urban Health. 2005; 82: 216-224Crossref PubMed Scopus (180) Google Scholar, 27Nash D. Azeez S. Vlahov D. et al.Evaluation of an intervention to increase screening colonoscopy in an urban public hospital setting.J Urban Health. 2006; 83: 231-243Crossref PubMed Scopus (112) Google Scholar For this reason, at Denver Health we are now focusing our quality improvement efforts in this area. Safety net systems often provide health care for incarcerated patients. In this study, we found that such patients had significantly worse bowel preparation and colonoscopy completion rates than all other groups. Detailed interviews of both patients and prison staff might shed more light on these findings. According to one staff gastroenterologist (personal communication, Neil Toribara, MD, PhD, Denver Health and Hospital Authority Endoscopy Laboratory, 2007), a possible if partial explanation is that some incarcerated patients refuse at the last minute to complete the bowel preparation and decline to be transported to the endoscopy lab because they are concerned that they will be assigned a new prison cell—and cellmate—when they are returned to prison. Uniform policies on the part of correctional care administrators and clear, advance communication with patients might help to mitigate these types of fears. Our findings are limited by a paucity of patient-level data. For example, we did not conduct interviews or surveys to better understand patients' own reasons for nonattendance. In addition, our results represent the experience of a single institution. Although bowel preparation quality ratings were not standardized across endoscopists, ratings at the extremes of the scale, including poor, were most likely to be consistent across providers. Although nonattendance rates might have improved during the spring and summer after our 6-month observation period, the 2006 winter season in Denver, Colorado was quite mild. Finally, because our focus was on the problem of colonoscopy nonattendance during a 6-month period, we were unable to enrich our findings by determining the proportion of patients who eventually completed colonoscopy as a result of rescheduling. Anecdotally, nonattendance and poor bowel preparation are common in safety net systems across the United States. This study formally characterized rates of colonoscopy nonattendance and inadequate bowel preparation within such a system. It is likely that our findings have relevance beyond our own institution. We look forward to learning about the experience of similar institutions and about interventions that can mitigate the inefficient use of this expensive, limited resource while increasing rates of screening and medically indicated diagnostic colonoscopies in vulnerable patient populations. A New Paradigm for Increasing Use of Open-Access Screening ColonoscopyClinical Gastroenterology and HepatologyVol. 6Issue 4PreviewColorectal cancer (CRC) remains a leading cause of cancer incidence and mortality in the United States.1 CRC takes a particularly high toll on African Americans, who suffer a disproportionate burden of disease relative to whites. Unlike other cancers, however, screening has been shown to be not only a cost-effective strategy for reducing mortality through early detection, but also for reducing incidence through the identification and removal of precancerous adenomatous polyps. Moreover, sufficient evidence has accumulated to warrant widespread endorsement by most authoritative groups, including the American Cancer Society, the US Preventive Services Task Force, and the US Multisociety Task Force on Colorectal Cancer. Full-Text PDF