Adapting Colorectal Cancer Screening to a Post-COVID-19 World
By: Rob Marko-Franks
COVID-19 has upended projects, conferences, and strategic plans for healthcare providers all over the country. As staff are redirected toward COVID-related work like testing and contact tracing, patients with other conditions could be left behind. For those with chronic conditions, this could be disastrous. COVID-19 also distracts from preventive work that providers, like community health centers, offer. Prioritizing screenings, healthy habits, and preventive treatments can help patients avoid numerous diseases that could ultimately cost them their life.
Unfortunately, colorectal cancer screening (CRCS) is one of the practices that had to take a backseat to the COVID-19 response. Colorectal cancer is one of the most common cancers; one out of 20 Iowans will be diagnosed with CRC during their lifetime. It is also lethal, being the second-leading cancer killer in the United States despite being highly treatable. People infected may not seek out potentially lifesaving treatment, partly because colorectal cancer is often asymptomatic. Screening can prevent that tragedy.
Colorectal Cancer Screening Before and During COVID-19
Eastern Iowa Health Center (EIHC), a community health center located in Cedar Rapids, prioritized colorectal cancer screening at all of their locations by identifying patients who were due for a screening by age and/or family history. Those identified as at greater risk were given the choice of a fecal immunochemical test (FIT) or colonoscopy. EIHC integrated colorectal cancer screening and education into patients’ annual wellness visits, acute visits, and other visits to the health center. A tracking tool also alerted providers when a patient was due for a screening.
EIHC staff always provided education about the need for this type of screening and the procedures themselves. They also confirmed the patient understood which procedure they selected and would follow through with the test.
When COVID-19 came to Iowa, much of that preventive screening had to stop. In-person visits were not taking place due to the need for social distancing. With patients no longer in the office, there was no opportunity to discuss preventive screenings. EIHC responded to these changes by increasing outreach to their patients. They called patients to gauge their knowledge of CRCS and their willingness to receive a FIT test in the mail. Obviating the need for a trip to the clinic, fecal immunochemical tests can be done at home. EIHC staff talked uninterested patients through some of the finer points of colorectal cancer, including its lethality and morbidity.
From early feedback, the approach is working! EIHC’s screening rates have increased from March to June, despite COVID-19 diverting much of their staff. They have maintained the capacity to triage when they receive a positive FIT test and refer the patient to appropriate resources. Until they can resume in-person visits and prioritize regular preventive screening and patient education, EIHC is doing what they can to encourage remote testing.
The Future of Colorectal Cancer Screening
Barriers remain, and EIHC is looking for opportunities to improve the program. One hard-to-reach patient population, the homeless, can’t access this distance screening service. On the other hand, in-person colonoscopies require a visit to an offsite gastrointestinal (GI) clinic and the use of a sedative. After the procedure, patients require a companion and reliable transportation to ensure they get home safely while the sedative’s effects wear off. Both of these aren’t available to EIHC’s homeless patients. EIHC has allocated some money for transportation assistance to the health center and to arrange for someone to accompany the patient and wait for them while they undergo the procedures, but this program is still in its infancy. EIHC is exploring community partnerships and care delivery solutions that can make this preventive service more accessible and equitable.
Problems also exist beyond patient barriers to care. The frequent calls EIHC places to educate their patients, learn about barriers to receiving and seeking care, and confirm screening appointments are not reimbursable through Medicaid, Medicare, and many private insurance plans. Currently, most healthcare providers cannot receive payment for preventive services like those offered by EIHC. To improve outcomes, we must reward providers for preventing harmful and costly conditions like colorectal cancer by compensating them for diagnostic and person-centered care through a value-based care system.
Avenues to increase colorectal cancer screening rates include community partnerships, improved outreach through reimbursable phone, text, and telehealth contacts, and expanded remote testing options . These are some of the solutions community health centers are pursuing. As COVID-19 changes what is possible, safe, and effective, everything should be on the table to preserve the health of our patients, no matter their condition or situation.
Kelly DiAllesandro is the Care Coordination Manager with Iowa Primary Care Association.