National CRC Screening Summit | 2025-Ciemins (Updated)

Ciemins (Updated)

Pdf Summary

The presentation "Closing the Screen: CRC Screening Follow-up Rates, Predictors, Measurement & Learning Collaborative Insights" by Elizabeth L. Ciemins of AMGA focuses on colorectal cancer (CRC) screening follow-up (FU) rates, measurement development, predictors, and quality improvement practices across U.S. health care organizations.<br /><br />Key findings indicate that recommended colonoscopy follow-up after a positive stool-based CRC screening test (fecal immunochemical test [FIT] or multi-target stool DNA [mt-sDNA]) occurs about 51.4% of patients within 6 months and 56.1% within one year. Follow-up rates vary significantly by race, insurance type, and test type, with lower FU rates observed among Black or Asian patients, Medicare/Medicaid beneficiaries, and FIT test users. Substantial variability in FU rates exists across health care organizations, and providers often lack awareness or internal tracking of FU completion. <br /><br />To address this, AMGA developed and tested a reliable, feasible CRC Screening Follow-Up Measure assessing timely colonoscopy completion within 6 months of a positive stool test. Testing included sensitivity, reliability, and feasibility assessments across diverse organizations and electronic health records (EHRs). Results showed that 96% of variability was due to differences between organizations, highlighting potential for improvement.<br /><br />AMGA’s CRC Screening Best Practices Learning Collaborative has engaged 20 health care organizations using shared learning, coaching, site visits, and quarterly benchmarking to raise CRC screening and FU rates. Metrics included “up to date” (UTD) screening and follow-up colonoscopy within 90 days. Participating organizations showed improvements averaging nearly 5 percentage points increase in UTD screening and follow-up rates, though national targets (e.g., Healthy People 2030 goal of 80% screening) remain challenging. Meeting a 72% follow-up goal would require either 2,020 additional colonoscopies (a 2.7% increase) or shifting existing colonoscopies to prioritize follow-ups.<br /><br />Successful interventions identified include organized tracking, closed-loop referral processes, timely patient contact, transparent reporting, and EHR integration with clinical decision support and outreach tools. Epic EHR best practices include health maintenance tracking, patient portal messaging, bulk outreach campaigns, and streamlined ordering workflows.<br /><br />In summary, improving CRC screening follow-up requires reliable measurement, provider engagement, system-level process innovations, data transparency, and patient-centered outreach. AMGA’s collaborative framework demonstrates measurable improvements and a pathway to closing care gaps in colorectal cancer prevention.

Keywords

Colorectal Cancer Screening

Follow-up Rates

Colonoscopy Completion

Fecal Immunochemical Test (FIT)

Multi-target Stool DNA (mt-sDNA)

Health Care Organizations

Electronic Health Records (EHR)

Quality Improvement

AMGA Learning Collaborative

Health Disparities