Original article—alimentary tract
Colonoscopy Completion in a Large Safety Net Health Care System

https://doi.org/10.1016/j.cgh.2007.12.003Get rights and content

Background & Aims: Anecdotally, patients in safety net health care systems have difficulty completing screening and diagnostic colonoscopies, but this is poorly characterized. It is important to understand this phenomenon to improve low rates of colorectal cancer screening in vulnerable populations and to ensure that patients with signs and symptoms complete medically indicated colonoscopic evaluations. Methods: We performed a 6-month retrospective review of outpatient endoscopy laboratory scheduling and procedure logs and electronic medical records at Denver Health Medical Center (DHMC), a large safety net health care system, to describe rates and sociodemographic predictors of colonoscopy nonattendance and inadequate (fair/poor) bowel preparation. Predictor variables included patient age, gender, race/ethnicity, procedure indication, and insurance type. Results: The nonattendance rate was 41.7% for all scheduled outpatient colonoscopies without difference between screening and diagnostic procedures. Consistent with non–safety net systems, the rate of inadequate bowel preparation was 30.2%; however, the rate of poor bowel preparation that absolutely precluded an exam was 9.9%. Correctional care patients had markedly higher rates of nonattendance and inadequate bowel preparation compared with other groups. Conclusions: A very large proportion of patients scheduled for colonoscopy in a large safety net health care system do not attend their procedures, and among those who do, there is a high rate of inadequate bowel preparation leading to incomplete and aborted evaluations. Interventions are needed to promote the more efficient use of a limited and expensive resource and to achieve higher rates of screening and medically indicated diagnostic colonoscopies in vulnerable patient populations.

Section snippets

Study Setting and Population

The study was carried out at Denver Health Medical Center (DHMC), a large community-based medical facility that serves more than 25% of Denver County residents. Fourteen percent of DHMC patients are black, and 54% are Latino. Approximately 65% of patients are below 185% of the federal poverty level, and uninsured patients account for 42% of all charges. DHMC also provides services for incarcerated patients in the City and County of Denver.

Screening and surveillance colonoscopies at DHMC are

Results

The final sample included 817 patients scheduled for outpatient colonoscopy. The overall nonattendance rate was 41.7% (Table 1). Less than 5% cancelled their procedures with less than 48 working hours notice; the vast majority simply did not arrive for the exam. Contrary to previously published observations, female sex, younger age, black and Latino race/ethnicity, and procedure indication were not associated with higher rates of nonattendance. However, attendance was significantly higher than

Discussion

Colonoscopy nonattendance was extremely high in almost all patient groups within a large safety net system. In addition, although 30.2% of patients who attended their appointments had an inadequate bowel preparation, consistent with a rate quoted in a recent meta-analysis of non–safety net systems,13 the rate of poor (as opposed to fair) quality preparation was 9.9%, which guarantees that at least 1 in 10 patients could not complete any meaningful portion of an exam. Thus, when poor bowel

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    Supported in part by the American Cancer Society MRSG-06-081-01-CPPB, principal investigator, Dr Denberg.

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