Interventions to improve colonoscopy completion among patients with abnormal fecal immunochemical tests (FITs) should be informed by clinician-identified barriers and facilitators, according to a study published in JAMA Network Open.

FIT has become a cornerstone for colorectal cancer (CRC) screening in many medically underserved populations; however, the proportion of patients with an abnormal FIT result who complete a diagnostic colonoscopy rarely exceeds 50% in most safety net health care settings and federally qualified health centers (FQHCs). Therefore, researchers sought to describe clinician-identified barriers and facilitators to colonoscopy completion among patients with abnormal FIT results. They aimed to identify interventions for improving follow-up and CRC outcomes in FQHCs and safety net systems.

Researchers conducted semi-structured key informant interviews from February to December 2020 with 10 primary care physicians (PCPs) and 11 staff members from a large safety net health care system in Washington state.

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The researchers found that the barriers to follow-up colonoscopy completion included environmental factors (i.e., social determinants of health and organizational factors) and patient cognitive factors. While resources that addressed these barriers (e.g., insurance assistance, appointment reminders, and bowel preparation education) were associated with improved colonoscopy completion, they were insufficient to meet national follow-up colonoscopy goals and have yet to be systematically implemented or evaluated.

The study was limited by its inclusion of a unique patient population found in an urban safety net teaching hospital, potentially limiting its generalizability. Additionally, clinician-patient interviews were not conducted. Thus, any barriers and facilitators that may have been identified by patients were missed.

The authors concluded, “In this qualitative study, responses of interviewed PCPs and staff members suggested that the barriers to colonoscopy completion in a safety net health system may be modifiable.” They added, “These findings suggest that interventions to improve follow-up of abnormal FIT results should be informed by clinician-identified factors to address multilevel challenges to colonoscopy completion.”


Issaka RB, Bell-Brown A, Snyder C, et al. Perceptions on barriers and facilitators to colonoscopy completion after abnormal fecal immunochemical test results in a safety net system. JAMA Netw Open. 2021;4(8):e2120159. doi:10.1001/jamanetworkopen.2021.20159