Multilevel health system intervention to increase surveillance colonoscopy for high-risk colorectal polyps

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Project Summary/Abstract Each year, colorectal cancer (CRC) is diagnosed in 147,950 Americans and is responsible for over 53,200 deaths in the United States (U.S). The foundation of CRC screening is the detection and removal of precancerous colon and rectal polyps, which reduces CRC incidence and mortality. One million Americans are diagnosed with high-risk neoplasia (HRN) during screening colonoscopy every year, a specific subgroup of colorectal polyps that are associated with a 2- to 5-fold increased risk for subsequent HRN, CRC, and death from CRC. HRN removal prevents CRCs and saves lives. Consequently, professional medical societies recommend that individuals with HRN undergo surveillance with repeat colonoscopy 3 years after HRN diagnosis. While many research efforts focus on increasing CRC screening for average-risk Americans, few studies address low surveillance rates in this high-risk group. Lack of surveillance after a HRN diagnosis is due to multiple factors, including patient (e.g., no knowledge surveillance is due), provider (e.g. task overload, interpretation of colonoscopy and pathology findings), and healthcare system (e.g., no tracking or recall of HRN patients at 3 years) barriers. Therefore, in order to increase HRN surveillance rates, we propose to implement and evaluate a multilevel, technology- assisted intervention that automatically and reliably identifies patients with HRN, prompts patients and providers when surveillance is due, and facilitates colonoscopy referral and scheduling. The intervention will be implemented in UCLA Health, a large academic integrated health delivery network with over 15,100 screening colonoscopies performed and approximately 1,810 HRN diagnosed annually. It harnesses the strengths of a multidisciplinary research team representing clinical medicine, health services research, medical informatics, natural language processing (NLP), population health, economics and implementation science. The specific aims of the proposed R01 are: 1) to gain stakeholder perspectives on our proposed multilevel intervention and assess potential barriers and facilitators to receipt of surveillance colonoscopy; and 2) to conduct a hybrid type 1 effectiveness-implementation cluster-randomized trial to assess the effectiveness, implementation, and cost of a multilevel intervention aimed to improve colonoscopy surveillance rates for patients with HRN. The proposed study fills an important gap in CRC prevention and focuses on a high-risk group that has been largely neglected in CRC research. Furthermore, this approach has the potential to change clinical practice, is easily portable for addressing other types of polyps and surveillance intervals, and can be adapted for other health systems that face the similar challenge of identifying and recalling patients at elevated risk for CRC.