Colorectal cancer screening in Appalachian Kentucky primary care clinics during COVID-19

ABSTRACT

Background: Colorectal cancer (CRC) mortality is disproportionately higher in Appalachian counties of Kentucky than in non-Appalachian regions. Part of the mortality gap can be explained by lower screening rates in Appalachian counties. Researchers at Markey Cancer Center partnered with primary care clinics in eastern Kentucky to address this disparity by identifying strategies to implement evidence-based interventions (EBIs) to improve CRC screening and follow-up in Appalachian Kentucky. Methods: Members of the research team conducted formative research activities to identify multilevel barriers to CRC screening. A menu of EBIs was then created to address these barriers, and clinic champions selected EBIs that were feasible in their respective practices. However, because of restrictions during COVID-19, clinics experienced multiple changes to workflow and operations, necessitating modifications to program activities. Over a series of virtual meetings, clinic champions selected adaptations that could allow clinics to continue promoting CRC screening in their practices despite COVID-related limitations. Results: Changes in clinic staffing and workflow resulting from COVID-19 included provider furloughs, a state-mandated pause in elective procedures, mandatory parking lot visits for many in-person visits, and an increase in telehealth. Among our clinic partners, total in-person visits were reduced by nearly half from first to second quarter of 2020, whereas telehealth visits were 23 times higher, though telehealth visits were cut in half by third quarter. To match these changing modes of practice, clinics adapted creative strategies for communicating CRC screening recommendations to patients, including shifting from paper to digital educational tools, promoting screening via telehealth visits, and prioritizing recommendations for stool-based tests over colonoscopy for average-risk patients. As a result, orders for FIT and FIT-DNA were 2 and 3 times higher, respectively, from second to third quarter of 2020. Conclusion: Rural primary care clinics in Appalachia continue to promote CRC screening despite the multiple challenges related to COVID-19. One relevant reference for clinicians is the National Colorectal Cancer Roundtable's playbook for reigniting CRC screening during COVID-19, a document that promotes stool-based screening for average-risk patients. While elective procedures remain backlogged in rural areas due to state regulations, research partners should emphasize the need to prioritize stool-based CRC screening for average-risk populations and reserve scheduling colonoscopies for high-risk individuals or those with abnormal stool-based test results. While our clinical partners had previously focused on a “colonoscopy first” approach to screening, our findings suggest that our clinic partners increased orders for stool-based CRC tests. Nevertheless, continued outreach is needed to ensure CRC screening rates remain optimal.