Cassandra Fritz

Evaluating screening colonoscopy quality in an uninsured urban population following patient navigation

Patient navigation (PN) increases screening colonoscopy completion in minority and uninsured populations. However, colonoscopy quality is under-reported in the setting of PN and quality indicators have often failed to meet benchmark standards. This study investigated screening colonoscopy quality indicators after year-one of a PN initiative targeting the medically uninsured. This was a retrospective analysis of 296 outpatient screening colonoscopies. Patients were 45 to 75 years of age with no history of bowel cancer, inflammatory bowel disease, or colorectal surgery. The screening colonoscopy quality indicators: adenoma detection rate (ADR), cecal intubation rate (CIR), and bowel preparation quality were compared in 89 uninsured Federally Qualified Health Center (FQHC) patients who received PN and 207 University Hospital patients who received usual care. The FQHC PN and University Hospital cohorts were similar in female sex (69% vs. 70%; p = 0.861) and African American race (61% vs. 61%; p = 0.920). The FQHC PN cohort was younger (57 years vs. 60 years; p < 0.001). There was no difference in ADR (33% vs. 32%; p = 0.971) or CIR (96% vs. 95%; p = 0.900) comparing the FQHC PN and University Hospital cohorts. The FQHC PN patients had a greater likelihood of an optimal bowel preparation on multivariate logistic regression (odds ratio 4.17; 95% confidence interval 1.07 to 16.20). Uninsured FQHC patients who received PN were observed to have intra-procedure quality indicators that exceeded bench-mark standards for high-quality screening colonoscopy and were equivalent to those observed in an insured University Hospital patient population.

Abstract B77: Knowledge of screening colonoscopy results and follow up recommendations among navigated patients

Purpose: Patient navigation (PN) programs have increased colorectal screening (CRS) rates in uninsured patient populations. The University of Chicago (UC) partnered with the American Cancer Society (ACS) to develop a CRS initiative at the UC to improve CRS outcomes. Unlike many PN programs, the UC ACS program solely utilized community-placed navigators. Along with addressing barriers, navigators provided one-to-one patient education, pre-procedure instructions, scheduling, appointment and bowel prep reminders. Prior to their screening exam, none of the UC navigated patients had ever received care within the UC network. The efficacy of CRS programs depends on patient awareness of results and follow-up recommendations. Currently, the only data on awareness of colonoscopy surveillance recommendations is limited to a predominantly Caucasian insured population with known adenomas. Yet it is unclear what a predominately African- American navigated patient population knows about their colonoscopy results and follow-up recommendations. Therefore, our objectives were to determine UC navigated patients9 knowledge of colonoscopy results and follow-up recommendations compared to non-navigated patients. Methods: Between Jan. to June 2014, 194 patients obtained a screening colonoscopy with one of the physicians, who were also providers for the UC ACS program. Most, 143 patients met inclusion criteria (navigated patients: initial screening colonoscopy, asymptomatic, uninsured, and age > 45 / non-navigated patients: screening colonoscopy, asymptomatic, insured, and age >45). A brief semi-structured telephone survey was utilized to assess patient9s beliefs about CRS, knowledge of their results, and follow-up recommendations. All patients were surveyed between 4-25 weeks post colonoscopy. Statistical analysis included chi-square and logistical regression (p Results: Of the 143 patients meeting inclusion criteria, 97 patients were reached by phone (68%). Only 1 patient refused to complete the survey providing a 98% response rate. Of the 25 ACS patients meeting inclusion criteria, 18 patients completed the survey compared to 78/119 non-navigated patients. Around 90% of the navigated patient population identified as African American (AA), compared to 64% of the non-navigated patients. There were no statistically significance differences between navigated and non-navigated patients for sex, ethnicity, race, and education level. Non-navigated patients were more likely to report a higher income and having a primary care physician (p Approximately 40% of navigated patients said “no” or “unsure” when asked if colon cancer could be prevented compared to 35% of non-navigated patients (p = 0.37). 100% of the navigated patients correctly reported their colonoscopy findings compared to 79.5% of the non-navigated patients (p=0.04). ACS navigation was the only significant variable found on logistical regression. In contrast, only 44.4% of the navigated patients reported the correct follow-up recommendations compared to 70.5% of non-navigated patients (p=0.04). Logistical regression analysis showed that level of patient education (OR=.32; p=0.02) and having an adenoma (OR=4.1; p=0.02) correlated with knowledge of follow-up recommendations. Conclusions: Despite education and access to care, our study highlights the need for continued education around CRS, since less that 40% of both navigated and non-navigated patients reported screening as a colon cancer preventative procedure. Although navigated patients were more aware of their colonoscopy results than non-navigated patients, this patient population was less aware of their follow-up recommendations. Future studies need to focus on minority populations in order to ensure equal benefit from CRS and to reduce disparities from this often-preventable cancer. Citation Format: Cassandra D.L Fritz, Keith Naylor, Karen Kim. Knowledge of screening colonoscopy results and follow up recommendations among navigated patients. [abstract]. In: Proceedings of the Seventh AACR Conference on The Science of Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; Nov 9-12, 2014; San Antonio, TX. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2015;24(10 Suppl):Abstract nr B77.

Abstract A49: From community-based participatory research to community-based participatory education: The implementation of community participation in cancer disparities curriculum development

Background: The Chicago South Side Cancer Disparities Initiative is a partnership between the University of Chicago and Chicago State University with the primary aim of developing a multi-faceted approach to cancer disparities education, training, and outreach. The current literature on direct community participation in curriculum development is minimal. Therefore, we developed a community-based participatory education (CPBE) model to provide community appropriate solutions to reduce local cancer disparities. In this study, CBPE was applied to develop a cancer-related health disparities curriculum for medical and public health students. Objective: To use CBPE to develop a community-oriented cancer disparities curriculum that is specifically designed to assess the following content areas: 1) Are local communities interested in participating in curriculum design? 2) What should we teach students about disparities in their community? 3) How should community members be involved in the design and implementation of the curriculum? 4) What topics do community members think we should address? Methods: A community town hall format was used to seek answers to the four content areas. Eighty-six community members from 19 different zip code areas of Chicago attended the town hall meeting. Participants were 14% men, 86% women with an average age of 51.7 years. An electronic Audience Response System (ARS) was used for the anonymous rapid collection of community response data. Using a mixed method approach, 4 quantitative and 3 qualitative survey questions were analyzed. Results: 80% of community members heard of health disparities, 93% thought community members should be involved in cancer disparities curriculum development, 85% want to be involved in designing a cancer disparities curriculum and 81% reported an interest in taking the cancer disparities course. Categorical themes were derived from the analysis of open-ended survey responses to potential curricular skills, knowledge and content. General questions followed by categorical themes are listed below: 1) What should students know to successfully interact with your community? a) Importance of Community Empowerment b) Root Causes and Solutions of Disparities c) Knowledge specific to local community needs 2) How should community members be involved in curriculum design? a) Student experiences in community engagement b) Community perspectives on experience with disparities 3) What are the topics the disparities curriculum should address? a) Root cause of Cancer Disparities b) Solutions-“Prescription for Change” c) Development of diverse relationships and interactions Conclusion: The goal of Community Based Participatory Education (CBPE) is to directly involve community in health professional curriculum development. In this study, we outline the active role of the local community in creating an integrated cancer disparities curriculum for both health professionals and the community. The multiple themes identified will be used to prioritize and develop the curriculum. CBPE will provide the infrastructure for community appropriate solutions to reduce the number of health disparities plaguing the south-side Chicago community. Citation Format: Cassandra D.L Fritz, Keith Naylor, Yashika Watkins, Thomas Britt, Lisa Hinton, Jennifer Jones, Gina Curry, Helen Lam, Karen Kim. From community-based participatory research to community-based participatory education: The implementation of community participation in cancer disparities curriculum development. [abstract]. In: Proceedings of the Sixth AACR Conference: The Science of Cancer Health Disparities; Dec 6–9, 2013; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2014;23(11 Suppl):Abstract nr A49. doi:10.1158/1538-7755.DISP13-A49

Abstract B88: Comparing screening colonoscopy bowel preparation quality in navigated uninsured and insured patient populations

Background: Racial and ethnic minority patients, as well as those with lower incomes and inadequate insurance, are less likely to complete preventative colorectal cancer (CRC) screening. Patient navigation is known to be an effective method for increasing the rates of CRC screening among minority groups and the medically underserved. The University of Chicago Medicine (UCM) is an active participant in the American Cancer Society9s Colorectal Cancer Screening Initiative (ACS CCSI). The ACS CCSI began in August, 2012 with a goal of increasing access to and utilization of CRC screening among uninsured Illinois residents. In support of the CCSI, the UCM has partnered with Federally Qualified Healthcare Centers located on Chicago9s South Side. Patients who participate in the CCSI at these healthcare sites receive: in-clinic patient navigation provided by an ACS trained navigator; they are provided GoLYTELY for bowel irrigation; and they are referred to UCM for screening colonoscopy. Prior to the day of their scheduled endoscopy, CCSI participants have no interaction or communication with the performing Gastroenterologist and they are responsible for adhering to the appropriate diet and completing the bowel preparation medications. Adequate bowel preparation is a quality measure for colonoscopy. Standard descriptors of bowel preparation include: “excellent”, no or minimal stool and small amounts of clear fluid; “Good”, no or minimal stool with large amounts of clear fluid; “Fair”, semisolid debris that are cleared with difficulty; and “Poor”, solid or semisolid debris that cannot be effectively cleared. Inadequate, “Fair” or “Poor”, bowel preparation is known to: lower rates of polyp detection; increase colonoscopy procedure duration; and contribute to earlier than recommended intervals for surveillance examination. Published studies have noted that uninsured patient populations are more likely to have an inadequate bowel preparation when compared with insured patient populations. The aim of this study was to assess bowel preparation among an insured university hospital population and an uninsured patient population who received navigation through the ACS CCSI. Methods: This is a retrospective chart review of colonoscopies performed between 08/01/2012 and 07/01/2013. Inclusion criteria: adults age 50 and above who were eligible for guideline consistent CRC screening. Exclusion criteria: Patients referred for screening colonoscopy by a gastroenterologist. These patients are excluded as they may have received additional patient education and/or procedure related instructions that would likely impact the quality of their bowel preparation. Endoscopy procedure reports were reviewed for bowel preparation quality. Bowel preparation was summarized as Excellent/Good or Fair/Poor. Chi-Square and paired T-tests where used for statistical analysis. Results: 228 outpatient colonoscopies were included in the review. 86 colonoscopies were performed as part of the ACS CCSI and 142 colonoscopies were performed as usual care. There was no difference in male gender comparing ACS CCSI and usual care (30% vs. 35%, p > 0.50). The average age of ACS CCSI patients was younger than usual care (56.3 vs. 61.9 years, p Conclusion: There are many barriers to effective CRC screening. Through the ACS CCSI, access to screening colonoscopies for the underserved in Illinois will increase. However, even with increased access, the quality of examination during colonoscopy can be impaired by inadequate bowel preparation thereby limiting its benefits and efficacy in preventing CRC. Our study found that an uninsured patient population that receives navigation through programs such as the ACS CCSI may achieve comparable, or in this population superior, rates of adequate quality of bowel preparation. Citation Format: Keith Naylor, Cassandra Fritz, Helen Lam, Karen Kim. Comparing screening colonoscopy bowel preparation quality in navigated uninsured and insured patient populations. [abstract]. In: Proceedings of the Sixth AACR Conference: The Science of Cancer Health Disparities; Dec 6–9, 2013; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2014;23(11 Suppl):Abstract nr B88. doi:10.1158/1538-7755.DISP13-B88

A New-Onset Rash in the Setting of Rifaximin Treatment for Hepatic Encephalopathy.

We present one of the first cases in the literature to describe an association between Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN) and rifaximin treatment in a patient with a recent diagnosis of alcoholic hepatitis, stage 2 hepatic encephalopathy, and no known existing allergies. Although SJS/TEN may be a rare reaction with rifaximin, it should be an important clinical consideration.