Telephone assessment increases uptake of colonoscopy in a FOBT colorectal cancer-screening programme

Abstract

In faecal occult blood test (FOBT) screening for colorectal cancer, face-to-face consultation for pre-colonoscopy assessment has significant resource implications. For this reason, providing the option of telephone interview for this purpose was evaluated. In the second year of the third round of screening in Tayside, all FOBT-positive individuals were offered pre-colonoscopy assessment by means of telephone interview. This was evaluated by comparing the results with those obtained in the first year, when only face-to-face consultation was available. Of 388 individuals offered the choice of telephone interview or face-to-face consultation, 330 (85.1%) chose telephone interview, and all but two of the remainder underwent face-to-face consultation. When compared with the preceding year, there was a highly significant reduction in the numbers not attending for colonoscopy (0.8% versus 14.9%, P < 0.0001) Telephone interview is an acceptable form of pre-colonoscopy assessment for the majority of FOBT-positive participants in a colorectal screening programme, and the policy of offering this approach is associated with a marked reduction in the colonoscopy default rate.

INTRODUCTION

Colorectal Cancer Screening using faecal occult blood testing (FOBT) has been shown in randomized trials to reduce disease-specific mortality. ¹ As a result the National Screening Committee recommended the setting up of a demonstration pilot to establish whether or not it would be feasible to introduce colorectal screening programme into the United Kingdom National Health Service. This pilot was carried out in two areas: Grampian, Tayside and Fife in Scotland and Coventry and Warwickshire in England. The results of the first round of this pilot, which was designed to simulate the first round of a biennial screening programme, have been independently evaluated ² and published ³ and as a result the United Kingdom Health Departments are now in the process of introducing National Screening Programmes. In Scotland three biennial rounds of screening were carried out as a pilot and the programme became national in June 2007 with a phased roll out programme that is expected to be complete by December 2009.

In the first two rounds of the Scottish pilot any individual who had a positive FOBT had pre-colonoscopy assessment by means of a face-to-face consultation with a specialist nurse. The nurse discussed the implications of a positive result, provided information about colonoscopy and the necessary preparation, assessed participants' fitness for colonoscopy and gave advice to those with significant co-morbidities including diabetes and conditions requiring anticoagulant medication. While effective in providing a means for individuals to make an informed choice about proceeding to colonoscopy and dealing with the practicalities of organizing a colonoscopy, it was recognized that this approach was labour intensive and required some participants to travel some considerable distances for the allocated appointment. Therefore, in the second year of the third round of screening it was decided to carry out an evaluation of assessment by telephone interview to establish whether or not this could, at least in part, replace the face-to-face consultation. The results of this evaluation are presented here.

METHODS

In the first year of the third round of the screening pilot men and women in Tayside who had been identified as positive by means of the screening algorithm utilizing a guaiac based FOBT ⁴ were invited by letter to attend an appointment with a specialist nurse as in the first two rounds of the pilot. However, in the second year participants were sent a letter offering them a choice of a face-to-face consultation or a telephone interview with a colorectal nurse specialist. If they failed to respond they were sent a reminder letter, and further non-responders were sent an appointment for a face-to-face consultation. The same interview protocol was used regardless of the preferred mode of assessment and it included explanations of the significance of a positive FOBT and the process of colonoscopy along with a description of the risks and benefits. The individual was then asked a series of questions to assess their fitness for colonoscopy. If the nurse specialist considered that all the issues had not been satisfactorily dealt with or if there was serious concern regarding fitness for colonoscopy then a face-to-face consultation was arranged. Any dubieties about fitness were also discussed with a colorectal surgeon or gastroenterologist.

If the assessment by telephone was satisfactory then an appointment for colonoscopy was organized and the bowel preparation materials were sent out in the post to the individual. If, at the first telephone contact, a face-to-face consultation was requested this was organized. After the colonoscopy had been completed, a questionnaire was sent out in the post to a randomly selected subgroup of those who had participated in a telephone interview; the specific questions posed are detailed in Table 1.

Table 1

Results of patient satisfaction questionnaires

Questions	Yes	No	No data
Was the telephone conversation acceptable to you?	87	2	1
During the telephone consultation was there too much medical information?	84	4	2
Were you made aware of the potential risks of having a colonoscopy?	82	6	2
Did you feel that you had enough time to discuss your concerns during the telephone call and to reach your decision about having a colonoscopy?	85	0	5
Were you satisfied with the support provided by the screening nurse during the telephone call?	84	2	4
Overall, has the care you received influenced you in a positive way to take part in future bowel screening programmes?	84	2	4

RESULTS

In the first year of this study a total of 316 individuals in Tayside had a positive FOBT; the age range was 51–71 years, and the median age was 61. There were 129 women (41%) and 187 men (59%). In the second year there were 388 FOBT-positive individuals, again with an age range of 51–71 and a median age of 61. In this case there were 165 women (42%) and 223 men (58%). In the first year, all participants were only offered a face-to-face consultation with a specialist nurse. In the second year, where a choice was made available, 330 requested assessment by telephone and 43 requested a face-to-face consultation. Thirteen did not respond after a reminder letter, and were sent an appointment. One participant was unable to be assessed by telephone and was sent an appointment for face-to-face consultation. Two prisoners were assessed by the prison nurse. In total, only two individuals did not undergo any type of assessment as they did not attend for the pre-arranged consultation (Table 2).

Table 2

Overall summary of participants in the telephone consultation strategy

Number of FOBT positive participants	Number requesting telephone interview	Number requesting appointment for consultation (including two prisoners)	Number not responding, and sent appointment for consultation	Number not assessed by any means
388	330 (85.1%)	43(11%)	13(3.4%)	2(0.5%)

In the first year 47 individuals (14.8%) did not attend for colonoscopy, of whom 45 did not attend for initial consultation. In the second year, however, of all the FOBT-positive individuals (including those who did have a face-to-face appointment) only three (0.8%) failed to attend for colonoscopy of whom two did not undergo assessment. This was a highly statistically significant difference (Table 3). There was no difference between the two years in the numbers of individuals having inadequate bowel preparation for colonoscopy or the numbers not attending for colonoscopy after assessment, either by face-to-face consultation or by telephone interview (Table 4).

Table 3

Numbers not attending for colonoscopy

	Total	Did not attend	%
First year – no telephone interview	316	47	14.9
Second year – telephone interview available	388	3	0.8

Difference = 14.1% (95% CI 10.1–18.1%)

P = 2.5e-14 (Fisher's exact test)

Table 4

Numbers with inadequate bowel prep and not attending for colonoscopy after assessment

	Inadequate bowel preparation	Non-attendance for colonoscopy after assessment
First year – no telephone interview	23 (8.5%)	2 (0.7%)
Second year – telephone interview available	22 (5.7%)	1 (0.3%)

In terms of satisfaction with the assessment by telephone interview, 121 questionnaires were sent out and 90 were returned. Six parameters were studied in this questionnaire and the majority of individuals were satisfied on all six counts (Table 1).

DISCUSSION

To our knowledge this is the first time that assessment by means of telephone interview has been used in the context of a National Screening Programme and the results clearly indicate that, in FOBT screening, this is an effective and acceptable method of providing information and preparing people with positive tests for colonoscopy. Indeed, as evidenced by the markedly reduced numbers of individuals failing to attend for consultation and thus for subsequent colonoscopy, telephone interview appears to have significant advantages. This is presumably related to the ability of participants to choose to have the mode of assessment most suitable or convenient to them, and has the potential for significantly improving the non-attendance rate for colonoscopy after a positive FOBT that was observed in the UK demonstration pilot of colorectal screening. ^2,3 It is also reassuring that quality of bowel preparation and attendance for colonoscopy after assessment were not adversely affected by the telephone interview strategy.

While this was not a randomized study, no other component of the screening programme changed between the first and second years of the third round. It is therefore very unlikely that attendance for colonoscopy could have been affected by any parameter other than the assessment policy.

Face-to-face consultation following a positive FOBT is a major consideration for a National Screening Programme and has significant resource implications. However, the data presented here demonstrate that telephone interview is acceptable for the majority of participants, and that a policy of face-to-face consultation for all does not appear to offer any advantages.