Prediciting and addressing colonoscopy non-adherence in community settings

项目摘要/摘要 在美国，结直肠癌是癌症死亡的第二大原因，而研究表明 结直肠癌筛查降低结直肠癌发病率和死亡率，仅65%符合条件的成年人 在2015年按建议间隔进行了筛查。更令人不安的是，那些接受筛查的人并没有 对于异常结果，总是得到及时的跟进护理。林恩·巴特利博士演示了患者导航 可以有效地提高新汉普郡低收入、未参保患者的结肠镜检查接受率， 提高率比常规护理高27个百分点(96.2%比69.3%，P&lt；.001)。使用停靠点的数据 在26个社区诊所的CRC研究中，我们的团队开发了一个可以对患者进行分层的风险预测模型 根据他们随访的结肠镜检查坚持的概率。我们的研究将回答一个关键问题 务实问题：患者导航能否有效改善以下患者的随访结肠镜检查 有中等或较低的概率坚持进行后续结肠镜检查；其次， 患者导航的有效性因患者的概率水平而不同？ 我们将在我们成功的正在进行的研究的基础上，测试由慢性疾病驱动的患者层面的干预 护理模式，以增加结直肠癌筛查的诊断随访。在目标1中，我们将验证 风险预测模型，根据风险对患者进行分层，并根据当地情况调整患者导航材料 资源和设置。在目标2中，我们将进行一项涉及28家诊所的双臂随机对照试验 (约1200名粪便检测呈阳性的患者)，并将比较患者导航和常规护理在提高发病率方面的差异 进行后续的结肠镜检查。我们将评估(1年内完成结肠镜检查) 计划总体情况，以及按类别划分的遵守后续行动的概率的有效性 结肠镜检查(中度与低度)。这项大规模、临床随机、双臂随访的结肠镜检查 计划将利用我们研究团队的专业知识，该团队已经实施了 在多个医疗保健环境中进行大量基于系统的干预，并使用电子健康记录 提供以临床为基础的干预的工具。我们将在这些成功的基础上进行最大规模的研究 到目前为止，阐述了在安全网诊所接受护理的患者中的结肠镜随访情况。这 研究可以优化患者导航的交付，支持患者导航的广泛采用 计划，并极大地提高这一弱势群体的结肠镜随访率。

PROJECT SUMMARY/ABSTRACT Colorectal cancer is the second-leading cause of cancer death in the U.S. While research has shown that colorectal cancer screening decreases colorectal cancer incidence and mortality, only 65% of eligible adults were screened at the recommended interval in 2015. Even more troubling, those who are screened do not always get timely follow-up care for abnormal results. Dr. Lynn Butterly demonstrated that patient navigation can effectively raise rates of colonoscopy uptake among low-income, uninsured patients in New Hampshire, boosting rates 27 percentage points over usual care (96.2% vs 69.3%, P<.001). Using data from the STOP CRC study of 26 community clinics, our team developed a risk prediction model that can stratify patients according to their probability of adherence with follow-up colonoscopy. Our study will answer a key pragmatic question: can patient navigation effectively improve follow-up colonoscopy among patients who have a moderate or low probability of adhering to follow-up colonoscopy; and secondarily, does the effectiveness of patient navigation differ by patients’ probability level? We will build on our successful ongoing research to test a patient-level intervention, driven by the Chronic Care Model, to increase diagnostic follow-up for colorectal cancer screening. In Aim 1, we will validate the risk prediction model, stratify patients according to risk, and adapt patient navigation materials to local resources and settings. In Aim 2, we will conduct a two-arm randomized-controlled trial involving 28 clinics (~1200 patients with positive fecal tests) and will compare patient navigation and usual care in raising rates of follow-up colonoscopy. We will assess the effectiveness (completion of colonoscopy within 1 year) of the program overall, as well as the effectiveness by category of probability of adherence to follow-up colonoscopy (moderate vs. low). This large-scale, clinic-randomized, two-arm follow-up colonoscopy program among safety net patients will leverage the expertise of our research team, which has implemented numerous systems-based interventions in multiple health care settings and used electronic health record tools to deliver clinic-based interventions. We will build on these successes in undertaking the largest study to-date addressing follow-up colonoscopy uptake among patients who receive care in safety net clinics. This study could optimize the delivery of patient navigation, support the broad adoption of patient navigation programs, and greatly improve colonoscopy follow-up rates in this vulnerable population.