In March 2020, the Department of Veterans Affairs (VA) enacted several preventive strategies, including instituting policies prioritizing medical procedures for early vs. delayed completion in response to the surging COVID-19 pandemic. This strategy, while intended to mitigate risk amongst Veterans at high risk of poor COVID-19 outcomes, could have profound health implications beyond the pandemic. Notably, nearly all colonoscopies were initially postponed for at least 12 weeks, with a 42% and 93% drop in monthly colonoscopy volume in March and April 2020, respectively. Impact of delays could be particularly profound for Veterans referred for colonoscopy for "red flag" signs or symptoms of colorectal cancer (CRC), who have greater risk for CRC incidence and mortality as well as later stage of CRC detection.
To address literature gaps regarding impact of time to complete diagnostic resolution and strategies for prioritization of colonoscopy for individuals with red flag signs and symptoms for CRC, we propose the following Specific Aims: Aim 1. Establish the COVID-19 CRC Risk Cohort (CV19-CRC), a cohort of Veterans with new documentation of red flag signs or symptoms of CRC including time periods before and after implementation of COVID-19 policies impacting colonoscopy scheduling. Aim 2. Examine stage at CRC detection for individuals completing colonoscopy before vs. after implementation of COVID-19 policies utilizing the CV19-CRC.
The CV19-CRC cohort was composed of adults ages 50-75 receiving VA care with a documented red flag sign or symptom during the study period. The study period was split into three timeframes: pre COVID-19 (April 2019-December 2019), a washout period (January 2020-March 2020), and post COVID-19 (April 2020-December 2020). Red flags included having an abnormal fecal immunochemical test or guaiac fecal occult blood test (FIT/gFOBT); iron deficiency anemia (IDA); or hematochezia. For Aim 1, the primary outcomes were proportion with red flag symptoms or signs with subsequent colonoscopy completion within each timeframe, and absolute time to colonoscopy from date of red flag sign/symptom identification. Multivariable Cox models were used to assess differences in time to colonoscopy between pre and post groups. Sociodemographic and other clinical characteristics associated with colonoscopy completion were measured to compare pre vs. post groups and adjust for confounding. For Aim 2, we will examine whether the COVID-19 crisis led to later stage at diagnosis among Veterans in CV19CRC cohort diagnosed with CRC. Analyses will be adjusted for propensity to receive early colonoscopy.
A red flag diagnosis was noted for 47,432 persons ages 50-75 receiving VA care between April 2019 and December 2020 (23,170 in pre COVID-19 period; 6,853 in washout period; 17,409 in post COVID-19 period). The predominant red flag identified in the pre and post periods was abnormal FIT/gFOBT. Median follow up time after red flag diagnosis was 84 days for the pre vs 77 days for the post period. Colonoscopy completion was slightly higher in the post COVID-19 group compared to the pre COVID-19 group (post vs. pre: 32% vs. 30%; p=0.003). Similarly, time to colonoscopy was slightly shorter in the post COVID-19 period compared to the pre COVID-19 period (post vs. pre: 42 vs. 46 days; p<0.01). When stratified by red flag type, individuals with IDA in the post period had shorter times to colonoscopy than those diagnosed with IDA in the pre COVID-19 period (post vs. pre: 49 vs. 60 days; p=0.02). The adjusted Cox model findings showed a 9% increase in colonoscopy uptake in the post group compared to the pre group (HR: 1.09; 95% CI: 1.05-1.13).
The COVID-19 crisis is an unprecedented health emergency that has imposed major limitations on healthcare systems. This pilot research contextualizes how COVID-19 affected colonoscopy completion within the VA among Veterans with red flags for CRC and its impact on CRC stage at detection. The findings suggest that VA policies for colonoscopy prioritization were successful in maintaining rates of colonoscopy completion and avoiding completion delays for Veterans with red flag signs and symptoms at highest risk for CRC. As such, VA policies may have mitigated impact of COVID-19 on CRC outcomes. These findings and the Aim 2 results set the foundation for future research to better understand the impact the COVID-19 pandemic broadly had on CRC care.
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Cancer, Outcomes - Patient
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