Social Determinants of Health: Are Colonoscopies Always Fit for Duty?

Federally qualified health centers (FQHCs) are bound by Uniform Data System quality metrics and typically need to layer on additional measures to participate in accountable care. Whereas a colonoscopy requires bowel preparation, transportation to and from examination, and sedation, a FIT can be completed with a single stool sample.2 The USPSTF evaluated FITs as saving 292 life-years per 1000 individuals screened if starting screening at age 50 years compared with colonoscopies at 310 life-years.2 This difference in a perfect world is real; however, real-world data show that half of colonoscopies ordered are never scheduled and that only 40% of patients are made aware of alternatives.3 The USPSTF also concluded that there are 40% more harms associated with colonoscopies, albeit at only 14 per 1000 procedures. [...]Black adults have the highest incidence of and mortality from CRC.6 Safety-net populations, consisting of Medicaid-insured and uninsured patients, have the lowest CRC screening rates compared with privately and commercially insured patients.7 Gupta et al highlighted many multilevel challenges that affect screening, from the level of the individual patient to providers/teams and national policy.8 On the individual level, personal attitudes, such as disgust and stigmas, have been shown to affect completion rates.9,10 From a structural perspective, patient access to CRC screening in general is inextricably linked to SDOH.11 When outcomes, quality, and cost are commingled with actual patient preference and adherence, a test that is "less perfect"—but more achievable by patients—could be the best, most efficacious choice. If that test also decreases the procedural burden in the local system of care such that those who need procedures receive more timely care, an additional societal benefit is achieved, as colonoscopy occurring 10 or more months after an abnormal FIT result has been associated with a higher risk of CRC and more advanced-stage disease at the time of diagnosis.12 To improve our performance in CRC screening, we analyzed FIT and colonoscopy data from our electronic health record (EHR) system (Intergy by Greenway), without making any changes in clinical practice other than beginning to systematically collect SDOH and assist patients with accessing resources.