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The American Journal of Managed Care April 2019
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Time to Fecal Immunochemical Test Completion for Colorectal Cancer
Cameron B. Haas, MPH; Amanda I. Phipps, PhD; Anjum Hajat, PhD; Jessica Chubak, PhD; and Karen J. Wernli, PhD
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Time to Fecal Immunochemical Test Completion for Colorectal Cancer

Cameron B. Haas, MPH; Amanda I. Phipps, PhD; Anjum Hajat, PhD; Jessica Chubak, PhD; and Karen J. Wernli, PhD
Targeted interventions by patient characteristics to improve fecal immunochemical test completion could reduce disparities in colorectal cancer screening and improve overall compliance with screening recommendations.
Identification of FIT Orders and Test Return

CRC screening guidelines at KPWA follow USPSTF recommendations as previously described.1 In 2011, KPWA clinicians replaced offering of the 3-sample SENSA gFOBT with the 1-sample FIT because of the improved diagnostic characteristics of the test, and they began to offer and distribute the FIT at routine clinical visits. Routine reminders are not part of the usual clinical workflow. Our cohort was defined as patients who received an order for a FIT between January 1, 2011, and December 31, 2012. From clinical laboratory data, we identified the date of FIT receipt with Current Procedural Terminology codes (ie, 82270, 82271, 82272, 82273, 82274) and Healthcare Common Procedure Coding System codes (ie, G01017, G0328, G0394).25,26

We excluded FIT orders due to (1) standing future orders (ie, automatic orders for future receipt of FIT) (n = 104); (2) orders that had a valid reason for being cancelled (see eAppendix [available at]), such as a new order for colonoscopy or flexible sigmoidoscopy, as those individuals are unlikely to complete a FIT in addition to other CRC screening (n = 2358); (3) inpatient orders (n = 44); and (4) orders included in the treatment arm of an ongoing randomized controlled trial (n = 81).27 Among the remaining orders, we selected the first order per patient as the index order for the start of follow-up. Our study was focused on average-risk adults; hence, orders from patients were excluded if they had a prior diagnosis of CRC (n = 66); full or partial colectomy, ileostomy, or proctectomy (n = 79); Crohn disease (n = 457); or ulcerative colitis (n = 496).

Patient Characteristics

Patient characteristics were selected based on identified risk factors for CRC.28 We obtained patient characteristics through administrative and clinical patient records. Age at the time of the FIT order was calculated based on patient date of birth. The calculated variable of BMI, based on the most recent measurements within the past year of FIT order, was extracted by the VDW from vital signs recorded at the corresponding clinical visit. We used the Charlson Comorbidity Index (CCI) score as of the date of FIT order, as well as status for specific comorbidities of interest.29

Self-reported race/ethnicity was grouped as non-Hispanic white (reference group), non-Hispanic black, Hispanic (all races), non-Hispanic Asian, non-Hispanic multiracial, and non-Hispanic unknown/missing race. Gender was binary as male (reference group) and female. Age at FIT order was divided into 5-year categories (50-54, 55-59, 60-64, 65-69, and 70-74 years), with the oldest as the reference category. Insurance status was grouped according to Medicare, commercial (reference group), and other payment options (including private pay, self-pay, and Medicaid). The most recent BMI measurement (within the past year) at the time of the first FIT order was categorized as underweight (below 18.5 kg/m2), normal (18.5-24.9 kg/m2) (reference category), overweight (25.0-29.9 kg/m2), and obese (30.0 kg/m2 and above).30 The CCI score31 was calculated with the lowest score (0) as the reference group and compared with groups of higher scores (1, 2, and 3 or more). Additional analyses were performed for 3 comorbidities with the highest prevalence in the sample population: diabetes, chronic pulmonary disease, and history of myocardial infarction. Receipt of any CRC testing (eg, FIT, colonoscopy) within the 2 years prior to the index date was recorded as a binary variable.

Statistical Analysis

We evaluated the association of demographic characteristics, CCI score, and medical conditions with the return of a FIT following clinician order. We performed time-to-event analysis from the date recorded of first FIT order until the date recorded for a received FIT. Individuals were censored for death, for disenrollment from KPWA, and at 365 days from the date of the first FIT order. We used 365 days as the end point because FITs are recommended as an annual screening tool; thus, patients could expect another order at the time of their annual visit. Time to completion was described using nonparametric Kaplan-Meier estimates, and differences between groups within variables were initially estimated by log-rank tests, with graphical display through 50 days from first FIT order. A univariate analysis was used to describe the mean, median, and interquartile range of time to completion of the FIT among those with a returned order. Among all patients in our population, Cox proportional hazard models were used to estimate unadjusted and adjusted hazard ratios (HRs) and 95% CIs comparing the time from order to receipt of FIT by patient-level factors with the variable-specific referent category. The adjusted model included all variables, without the specific comorbidities included in the CCI. Indicator variables were used for all variables in the models, which included an indicator for missing data where applicable. To estimate the adjusted HR for specific comorbidities, CCI score was removed from the model and replaced by each of the comorbidities in separate models. We used Breslow’s method for ties.32

Completion of FIT order, rather than incompletion, was the outcome of interest in this analysis to maintain consistency of interpretation with the results of the time-to-event analysis. Therefore, an HR greater than 1 indicates better FIT completion, a clinically positive outcome, and conversely, an HR less than 1 indicates a higher risk of the adverse outcome (ie, incomplete FIT).

All analyses were performed using SAS version 9.4 (SAS Institute; Cary, North Carolina). Additional analyses of each model were conducted in which categorical variables for age, BMI, and CCI scores were replaced with the corresponding continuous variable and tested for trends.

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