Colon cancer is the third leading cancer globally and the second dominant cause of cancer-related deaths in both males and females (Muthukrishnan, Arnold, & James, 2019). Locally, certain populations are at a higher risk of developing colon cancer than others. Individuals with chronic ulcerative colitis (UC) are 60% more likely to develop colon cancer than the average-risk population (Kinugasa & Akagi, 2016). Although colon cancer is a leading cancer nationally, it is also preventable through early detection. Screening colonoscopies have shown to be a far superior method for colon cancer screening, with one study noting that out of 9,845 participants 62 were diagnosed with colorectal cancer by surveillance colonoscopy and 3,861 had adenomatous polyps (Bretthauer et al., 2016).
To detect colon cancer sooner, it is important to follow colon cancer screening guidelines. Screening colonoscopies are recommended starting at age 45 and every 10 years until the age of 75 (American Cancer Society, 2020). For adults who have pancolitis or left-sided colitis diagnosed greater than 7 years, it is recommended they obtain a surveillance colonoscopy annually (Bae & Kim, 2014). Despite colon cancer being preventable, colon cancer rates are continuing to increase by 2% yearly since 1994 (Mauri et al., 2018).
Despite these recommendations, high-risk individuals continue to be overdue for colon cancer screening examinations. Data from an advanced search, of electronic health records at a Southeast Alabama gastroenterology clinic revealed that out of 20 adults with chronic UC, only five were up-to-date on surveillance colonoscopies. Not only are high-risk individuals overdue for screening colonoscopies but average-risk individuals are as well. The Centers for Disease Control and Prevention (CDC, 2013) note that one out of three adults in the United States (U.S.) have never been screened for colon cancer. Furthermore, 20 million individuals nationally are past due for colon cancer screening (CDC, 2013). These findings indicate that potentially 20 million individuals could develop a preventable deadly disease.
Background
Although surveillance colonoscopies are beneficial for early detection, they are often underutilized. One study indicated that out of 4,491 participants globally, only 2,482 underwent screening colonoscopies as recommended (Johnson et al., 2020). Risk factors for not obtaining recommended surveillance colonoscopies are risk of surgery, risk of developing colon cancer, and risk of death. There are also many barriers associated with not obtaining surveillance colonoscopies, with one of the most significant barriers being communication issues. One of the prevalent communication issues is patients being unaware of the need for a colonoscopy (Nagelhout, Comarell, Samadder, & Wu, 2017). This can be due to failure of the provider to make a recommendation or failure for the patient to keep scheduled office appointments. Communication is also interrupted when providers or clinics fail to obtain updated information on the patient such as a current home address and phone number.
Improving screening colonoscopy rates results in decreased colon cancer mortality rates and is more cost-effective. This is significant as colon cancer mortality rates continue to rise. Mortality rates from colon cancer in the U.S. are expected to increase from 32,395 to 48,515 from the years 2013 to 2035 (Araghi et al., 2019). On a localized level, mortality rates from colon cancer in adults with chronic UC are astronomical. The probability of death in patients with chronic UC diagnosed greater than 30 years who develop colon cancer is 50% (Kinugasa & Akagi, 2016).
Additionally, there is a multitude of increased costs associated with a colon cancer diagnosis. Some of these costs are related to chemotherapy, radiation, surgical procedures, and hospitalizations. The cost of chemotherapy increases with the length of treatment. Data have shown that one chemotherapy drug used to treat colon cancer for 6 months costs $34,317 (Nadeem et al., 2016). Radiation therapy for the treatment of colon cancer for 6 months can cost $133,495 (Raldow et al., 2019). Moreover, the average length of hospital stay for colon cancer is 11.1 days, with total hospital charges estimated at $4.57 billion annually (Seifeldin & Hantsch, 1999).
Prevention of colon cancer-associated costs is far less significant than associated colon cancer treatment costs. It is estimated that colon cancer screening with endoscopy costs between $968 and $3,352 (Pekez & Thakur, 2018). Thus, the prevention of colon cancer is more cost-effective for the patient and health insurance providers. Furthermore, preventing colon cancer with screening colonoscopies results in decreased mortality rates. Data showed that colon cancer-related deaths from the years 2000-2015 decreased by 52.4% due to routine surveillance colonoscopies (Levin et al., 2018).
Review of the Literature
To identify an appropriate intervention that would increase screening colonoscopy rates in adults with UC, an exhaustive search of the literature between the years 2010 and 2020 was performed. The databases assessed when searching the literature were PubMed, Google Scholar, and Cumulative Index of Nursing and Allied Health Literature (CINAHL). Keywords included in the search were implementing, phone, intervention, screening, colonoscopy, cancer, rates, and improving. The final search of the databases yielded 21 results from PubMed, 15 results from Google Scholar, and six results from CINAHL. Out of these 42 articles, three were articles on increasing screening colonoscopy rates, which informed the design of the initiative to promote implementing a combined phone and mail recall. The articles selected were based on relevance to the topic, strength of evidence, and positive outcomes.
Inclusion and exclusion criteria were applied when evaluating and deciding on the selection of appropriate research studies. Inclusion criteria included all studies conducted between the years 2010 and 2020, levels of evidence of at least I-III, and a research design of randomized controlled trial (RCT), systematic review, or meta-analysis. Also, all studies had to be written in English and include adults older than 18 years. Exclusion criteria included any studies that were not an RCT, systematic review, or meta-analysis; studies that involved individuals younger than 18 years; and any studies written in a language other than English. Studies not exhibiting levels of evidence of at least I-III were also excluded.
In reviewing the literature, several interventions increased colonoscopy rates but not all interventions noted a substantial increase. The intervention that produced the greatest increase in surveillance colonoscopy rates was implementing a phone recall combined with a mailed recall. This intervention was supported by three RCT studies. Several of these studies were analyzed using a multimodal approach to increase colorectal cancer screening rates instead of a singular approach.
Fiscella et al. (2011) and Kiran, Davie, Moineddin, and Lofters (2018) investigated using a combination of both phone and mail reminder recalls to increase colonoscopy rates. The study by Fiscella et al. (2011) included two mailed letters followed by a phone call a few weeks later. The letter informed the patient that he or she was overdue for colorectal screening and also provided educational material about why screening was important (Fiscella et al., 2011). Similarly, the study by Kiran et. al (2018) included a letter stating that the patient was overdue for colorectal screening, a pamphlet about colon cancer screening, and a number to schedule the procedure. The phone call included a reminder to inform the patient that he or she was overdue for screening and to schedule the procedure (Kiran et al., 2018).
One study analyzed using a multimodal approach and a singular approach to increase colorectal screening rates. Phillips, Hendren, Humiston, Winters, and Fiscella (2015) examined improving colon cancer screening rates with a mailed recall, phone recall, or both. The mailed letter stated that the patient was overdue for colorectal screening, explained why colorectal screening was recommended, provided the phone number to schedule the procedure, and addressed potential patient assistance. The automated phone calls had information comparable to the mailed letter. Some groups received only a letter or a phone call whereas other groups received a letter and a phone call (Phillips et al., 2015).
When evaluating the outcomes of all three studies, implementing either a phone or a mail recall did correlate with an increase in screening colonoscopy rates. However, the greatest increase occurred when the phone and mail recalls were combined. This was evidenced by Fiscella et al. (2011) and Phillips et al. (2015) noting an increase in screening colonoscopy rates by at least 28% when both phone and mail reminder recalls were combined. Furthermore, Kiran et al. (2018) commented that researchers recommended combining multiple strategies as the most effective way to increase colon cancer screening rates (Kiran et al., 2018).
Project Purpose
The utilization of screening colonoscopies has been shown to decrease colon cancer rates and should be kept up-to-date in average- and high-risk populations. Furthermore, early detection of colon cancer correlates with a decrease in associated healthcare costs and a decrease in mortality rates (Levin et al., 2018; Nadeem et al., 2016; Raldow et al., 2019; Seifeldin & Hantsch, 1999). Despite the positive outcomes associated with routine screening colonoscopies, rates remain low both globally and locally.
One of the barriers affecting colonoscopy rates is a lack of awareness (Nagelhout et al., 2017). Individuals are sometimes unaware that they are due for a screening colonoscopy. Certain populations such as adults with chronic UC are at a higher risk of developing colon cancer. Therefore, this population must remain up-to-date with surveillance colonoscopy examinations. The purpose of the evidence-based practice (EBP) project was to increase surveillance colonoscopy rates among adult patients with chronic UC.
In reviewing the literature there were multiple interventions identified to increase surveillance colonoscopy rates. The results were narrowed down to three studies that had the strongest evidence and best outcomes. These studies indicated that the best intervention to increase surveillance colonoscopy rates was by implementing a combined phone and mail recall with included educational material on the risks of colon cancer.
Methods
Ethics
The role of the institutional review board (IRB) is to certify the protection of research participants' human rights (Harris, Roussel, Dearman, & Thomas, 2018). The project leader sought IRB approval through Chatham University. The proposal submitted was considered an exempt proposal because the EBP project involves adults older than 18 years and excludes any vulnerable populations. IRB approval was secured on April 22, 2021, prior to the start of the EBP project.
Population
The project was conducted at a private gastroenterology clinic in Southeast Alabama. The clinic specializes in adults with inflammatory bowel disease. This clinic employs 10 physicians and 13 nurse practitioners (NPs) that provide care for adults with chronic UC. The participant population included 30 adult patients with chronic UC. To be included in the project, participants had to be between the ages of 18 and 80 years, be 1-2 years past due for a surveillance colonoscopy, and diagnosed with UC greater than 7 years. Participants also could not have any acute comorbidities that would prevent them from being a candidate for sedation. Participants were excluded from the project if they were older than 80 years or younger than 18 years. Participants were also excluded if they had a surveillance colonoscopy with in the previous 2 years and if they had any acute comorbidities that would increase the risk of sedation.
Initially, the project leader met with staff at the beginning of the project to conduct an informational session to ensure all staff members were aware of the project, understood the project details, and had contact information for the project leader. The project leader updated staff weekly on the project through email. Recruitment included posted flyers in the office, personal contact by the project leader, and providers at the clinic. The flyer informed participants of the project, who qualified for the project, and directed them to contact the front desk with the contact number provided, or to speak with their provider, if interested. If a participant was interested in the project, the front desk or the providers in the clinic notified the project leader. The recruitment phase was ongoing throughout the project.
Study Design
Meeting with participants was conducted individually with one in-person session and two virtual sessions. Following recruitment, the project leader met with each participant at the project site and provided the implied consent cover letter and the preimplementation self-created survey. The presurvey was used to collect demographic data and assess colon cancer risks and screening knowledge. The project leader was purposefully absent while the participant completed the presurvey. The participant dropped the completed survey in a box at the front desk labeled "presurveys." The neutral party responsible for picking up the pre- and postsurveys was the licensed practical nurse.
The second session was conducted virtually by phone. The project leader called each participant and reminded them that they were due for a surveillance colonoscopy, presented them with educational material on colon cancer risks, and offered them an opportunity to be transferred to the scheduling department or provided them with a contact number to schedule at a later time. If unable to reach the participant after three attempts within 1 month, the project leader assumed the participant had opted out of the project. After the second session, the participants were mailed a recall letter. Each letter contained similar information as the phone recall.
The third session was conducted virtually by phone and reminded participants to schedule their procedure. The project leader also provided the postsurvey during this call and informed the participant that a second postsurvey would be mailed at a later date for the participant to complete. The participant was informed that the survey was for collecting data only and that no identifying information would link the survey to the participant. The project leader placed completed postsurveys in a box at the front desk labeled "postsurveys." The project leader issued the same postsurvey by mail a few weeks later to determine that the survey was reliable. The participant was provided a preaddressed envelope with prepaid postage with the mailed survey. The participant was instructed to place the completed survey in the preaddressed envelope in the mail. Once the mail was received, the project leader dropped the envelopes in the post-survey box at the front desk.
After the mail and phone recall has been implemented, the project leader measured the outcomes of the project. During the measuring outcomes phase, the project leader gathered all pre- and postsurvey data as well as data from a chart audit. Data from the project was entered through Excel weekly. The project leader utilized descriptive statistics to analyze the data. After measuring the outcomes, the project leader disseminated the findings and outcomes of the project to key decision-makers via a poster presentation.
Screening Colonoscopy Survey
The participants' intent to follow through with scheduling a colonoscopy was measured using a self-created postsurvey tool. The postsurvey consisted of six 'yes' or 'no' knowledge questions and one multiple-choice question. The yes-or-no survey questions indicated if the participants knew the signs of colon cancer, if the participants with chronic UC should have a colonoscopy every 1-2 years, if colonoscopies detect colon cancer sooner, and if colon cancer is preventable. The multiple-choice question indicated if the participant had scheduled a colonoscopy, completed a colonoscopy, or intended to schedule a colonoscopy within the next 3 months. The postsurvey was tested for reliability by providing the same postsurvey to participants a few weeks later to ensure the test produced repeatable results (Twycross & Shields, 2004). Content validity was assessed by having an expert on the subject review the survey and ensure that the survey measured what the project leader intended for it to measure (Twycross & Shields, 2004).
Analysis
The goal was to increase colonoscopy rates in adults with chronic UC by 20%. This benchmark was based on the research study by Fiscella et al. (2011) where a similar intervention was implemented and the colonoscopy rates in that study increased by 28% (Fiscella et al., 2011). The project leader coded the data from the surveys as pre- and post. The project leader then used descriptive statistics in Excel for data analysis. All of the collected data were analyzed and reported as aggregate data. To measure if the intervention was effective in addressing the clinical problem, the project leader calculated a percentage increase from pre- and postsurvey data and calculated a percentage increase from pre- and post-chart audit data.
Results
There were approximately 500 patients with UC at the practice site. Out of the 500 patients, 30 participants were in the recruitment group. To be included in the recruitment group, participants had to be overdue for a screening colonoscopy by at least 24 months and diagnosed with UC for at least 7 years. Eligibility was determined during recruitment and a presurvey was utilized to aid in data analysis. After project implementation, there was one postcall issued and the postsurvey was conducted during this call.
The project outcome measured was an increase in screening colonoscopy rates in adults with chronic UC. The presurvey demographic question asked whether the participant had a colonoscopy in the last 2 years. The postsurvey multiple-choice question indicated whether the participant had scheduled a colonoscopy, completed a colonoscopy, or intended to schedule a colonoscopy within the next 3 months. The post-chart audit data indicated whether a participant had completed a colonoscopy within 3 months of project completion.
Data from the presurvey revealed that out of those 30 participants, zero participants had scheduled a colonoscopy or had a colonoscopy within the last 2 years. Data from the postsurvey revealed that 25 out of 30 participants had scheduled a colonoscopy, completed a colonoscopy, or intended to schedule a colonoscopy. A percentage increase was then calculated and determined to be 83%. Data from the pre-chart audit revealed that out of 30 participants, zero participants had scheduled a colonoscopy or had a colonoscopy within the last 2 years. Data from the post-chart audit revealed that 21 out of 30 participants had completed a colonoscopy within 3 months of project completion. A percentage increase was then calculated and determined to be 70%. Postsurvey data reflected that 83% of participants had scheduled a colonoscopy, completed a colonoscopy, or intended to schedule a colonoscopy post-project completion. Post-chart audit data revealed that completed screening colonoscopy rates in adults with chronic UC increased by 70% postproject implementation. See Figure 1 for a depiction of the percentage increase in colonoscopy rates from pre- and postsurvey data.
Discussion
A thorough analysis of the project data determines whether the project was effective at producing the desired results (Harris et al., 2018). The goal of this EBP project was to increase colonoscopy rates in adults with chronic UC by 20%. The intervention implemented for the project was determined to be effective. This was determined by a percentage increase in postsurvey data and post-chart audit data. Before the intervention, the presurvey data and pre-chart audit data for being up-to-date on screening colonoscopies were 0%. After the intervention, the postsurvey data for participants scheduling a colonoscopy, completing a colonoscopy, or intending to schedule a colonoscopy were 83%. After the intervention, the post-chart audit data for participants being up-to-date on completed screening colonoscopies was 70%. This data revealed that 70% of project participants were now current on their surveillance colonoscopies. It can be determined from these findings that the phone and mail recall was successful in increasing screening colonoscopy rates in adults with chronic UC at the practice site. The targeted benchmark was a 20% increase in screening colonoscopy rates and this project surpassed that goal.
Limitations
There were two main limitations noted when implementing the project. One of these limitations was that some participants could not meet in the clinic physically due to COVID-19. As a result, some meetings had to be conducted through a virtual platform, which required participants to have access to high-speed internet. Participation could have been limited due to decreased access to high-speed internet in some local rural communities.
The other limitation was financial hardship secondary to the pandemic. During the pandemic, unemployment was at a high resulting in a disconnect in telecommunication services for some people. This could have limited participation due to some participants not having phone access, preventing them from being able to participate in the phone recall portion of the project intervention.
Implications for Nursing Practice
Colon cancer is a leading cancer globally and screening colonoscopies are a far superior method for detecting colon cancer sooner (Bretthauer et al., 2016). For this reason, high-risk and average-risk populations must remain up-to-date on their screening colonoscopies. The American Cancer Society (2020) recommends routine screening colonoscopies starting at age 45 in the average-risk population.
One of the factors contributing to overdue screening colonoscopies is communication issues. Research studies indicate that some patients are unaware of the need for a colonoscopy (Nagelhout et al., 2017). This is often due to the failure of the provider to make a recommendation or the failure of the patient to keep scheduled office appointments. It is the provider's responsibility to ensure patients are up-to-date on their cancer screening examinations.
One major implication for nursing practice should be focused on increasing communication efforts. The CDC (2021) recommends utilizing patient reminders to ensure patients remain current on colon cancer screening examinations. Implementing a combined reminder recall system both locally and globally is one way to combat communication issues, which are a major factor contributing to overdue screening colonoscopies.
On a local level, issuing phone and mail reminders increased screening colonoscopy rates by 70%. This reveals that more focus should be placed on improving communication with patients and routinely communicating colon cancer screening recommendations. Not only does implementing a reminder recall system improve screening colonoscopy rates but it also decreases healthcare costs associated with colon cancer. Locally, implementing an advanced recall system saved the project site's organization $12,708 annually. Globally, implementing an advanced reminder system could save $40,000-$80,000 annually in Medicare costs (CDC, 2021). Efforts should be made to continually assess improving colon cancer screening rates. Implementing a reminder system that communicates colon cancer screening recommendations is one way to hopefully achieve this.
Conclusion
Colon cancer is noted to be the second cause of cancer-related deaths in both males and females (Muthukrishnan et al., 2019). Additionally, colon cancer rates are increasing in individuals younger than 50 years at an alarming rate of 2% annually since 1994 (Mauri et al., 2018). Furthermore, mortality rates from colon cancer in the U.S. are expected to increase by more than 15,000 in the next 22 years (Araghi et al., 2019).
Although colon cancer is a leading cancer globally, it is preventable through early screening. One effective way to screen for colorectal cancer sooner is through surveillance colonoscopies (Bretthauer et al., 2016). Although average-risk populations typically require a screening colonoscopy every 10 years starting at the age of 45, populations that are at a higher risk, such as adults with chronic UC, may require a surveillance colonoscopy every 1-2 years (American Cancer Society, 2020; Bae & Kim, 2014).
Although surveillance colonoscopies have been proven to be effective at detecting colon cancer sooner, they are often underutilized (Johnson et al., 2020). Risk factors for not obtaining recommended surveillance colonoscopies can include risk of surgery and even risk of death. Furthermore, the prevention of colon cancer results in decreased healthcare costs and decreased mortality rates (Pekez & Thakur, 2018). The use of screening colonoscopies has also been noted to prevent colon cancer-related deaths by at least 52.4% over 15 years (Levin et al., 2018).
One barrier that contributes to decreased screening colonoscopy rates is communication issues (Nagelhout et al., 2017). To combat this issue, this EBP project focused on implementing a combined phone and mail recall reminder in adults with chronic UC to increase screening colonoscopy rates. Participants were called and reminded that they were due for a colonoscopy as well as sent a reminder letter. Screening colonoscopy rates increased by 83% after the recall implementation indicating that implementing a recall system is effective at increasing colonoscopy rates.
It is imperative that average-risk and high-risk populations remain up-to-date on screening colonoscopies. Providers are responsible for ensuring that patients do not have a lapse in colon cancer screening services. This project as well as the literature demonstrate that practice sites could benefit from implementing an advanced reminder recall system to increase screening colonoscopy rates, ultimately improving mortality rates and healthcare costs.
REFERENCES