Steven Itzkowitz

Lecture Abstract

Patient Navigation: An efficient method of enhancing participation in screening colonoscopy among urban minorities. Steven Itzkowitz and Lina Jandorf. Departments of Medicine and Oncological Sciences, Mount Sinai School of Medicine, NYC, NY  10029

In the USA (and increasingly in other countries), colonoscopy has become the preferred screening test for colorectal cancer. Despite this, screening rates, particularly amongst urban minorities, are low.  Barriers to successful completion of colonoscopy can be viewed as: 1) physician-related (eg. lack of referral for colonoscopy); 2) organization-related (eg. limitations in scheduling or performing colonoscopy); and 3) patient-related (eg. behavioral issues such as fear, nihilism, fatalism, inconvenience). 

In 2003, at a time when the NYC Dept. of Health and Mental Hygiene was calling for improved colonoscopy screening rates for all New Yorkers, we set out to determine whether a Patient Navigator (PN), working within a system of open access colonoscopy referral, would enhance colonoscopy uptake ¹.  At that time, PNs were primarily used to help patients with an abnormal screening test get appropriate treatment, not for getting subjects into screening. Since colonoscopy is a much more complex screening test than mammography, Pap smears, and PSA tests, we reasoned that PN could have an important impact.  To avoid the barriers of inadequate health insurance or lack of physician referral, we initially only navigated patients who were referred by their primary care provider and had health insurance.  Referrals were first screened for medical clearance by a gastroenterologist and appropriate patients were then given to the PN.  Our PN was a Hispanic female health educator who contacted patients, explained the importance of colonoscopy and what to expect, answered questions about the prep, and helped arrange for their appointment (including sometimes helping arrange transportation and child care).  The PN sent a postcard to remind the patient of their appointment and made several phone contacts with patients.  After their colonoscopy, patients were given a brief questionnaire about the process. 

Of 1169 referrals, 688 patients qualified for and 532 underwent navigation.  Two-thirds (66%) of navigated patients completed screening colonoscopies, but unfortunately one-third still did not. We detected adenomas in 16% of subjects, and two stage I colon cancers.  Our "poor prep" rate was reduced from 12% to 5%, and the "no-show" rate was also reduced from 40% to 9.8%. Women were 1.31 times more likely to complete than men (p=0.014).  Hispanics were 1.67 times more likely to complete than African Americans (p=0.013).   Hispanic women were 1.50 times more likely to complete than Hispanic men (p=0.009).  Patient satisfaction was 98% overall, with 66% reporting that they definitely or probably would not have completed their colonoscopy without navigation.

Our current efforts are exploring whether peer navigators (individuals over age 50 who have had colonoscopy and are of similar ethnic background) are as effective as health educators for navigating patients into colonoscopy. We have also conducted focus groups with African American patients who refused colonoscopy which has helped to identify fears and myths about colon cancer that can be used to develop educational interventions in this more refractory group.

¹ Chen L, Santos S, Jandorf L, Christie J, Castillo A, Winkel G, Itzkowitz S.  A program to enhance completion of screening colonoscopy among urban minorities.  Clin Gastro Hepatol, 6:443-450, 2008.

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