Timely Follow-up of Positive Fecal Occult Blood Testing for Colon Cancer Screening: Travel Time Trumps Rural Residence

Charlton ME, Vaughan-Sarrazin MS, Kaboli PJ. Timely Follow-up of Positive Fecal Occult Blood Testing for Colon Cancer Screening: Travel Time Trumps Rural Residence. Poster session presented at: VA HSR&D National Meeting; 2011 Feb 17; National Harbor, MD.

Objectives: Positive results from fecal occult blood testing (FOBT) for colorectal cancer screening require prompt follow-up and expectation of colonoscopy within 60 days. Rural residence and/or distance from a VA Medical Center (VAMC) may hinder access to gastroenterology (GI) follow-up. Our objective was to determine if these factors impact FOBT follow-up. Methods: Using VA administrative data from the Austin Automation Center and PSSG, we identified 10,050 veterans ages 50 to 64 who were regular VA users, geocoded for rural residence and travel time to closest VAMC, and had positive FOBT in FY07. Primary outcome of interest was 60-day and 6-month follow-up by any of the following: colonoscopy CPT code, GI clinic stop code, or encounter with a GI provider. Multivariable logistic regression models adjusted for patient age, service-connected status, and comorbidity. Results: The study population was 100% male, 60% white, with mean age of 57.6 years; 61% were classified as urban and 39% rural; 75% lived < 90 minutes from a VAMC. A higher percentage of rural veterans had follow-up within 60 days compared to urban veterans (19.6% vs. 18.1%; P = 0.07) and within 6 months (33.8% vs. 30.3%; P < 0.01). Results were consistent with multivariable analyses in which rural veterans had higher odds of follow-up at 60 days (OR = 1.12; 95% CI 1.01-1.25) and 6 months (OR = 1.21; 95% CI 1.10-1.32). Counter to this finding was a lower percentage of veterans living > 90 minutes from a VAMC had follow up within 60 days (OR = 0.80; 95% CI 0.71-0.90) and 6 months (OR = 0.83; 95% CI 0.75-0.92). Implications: Our results show somewhat contrary findings in that rural veterans had a higher likelihood of follow-up for positive FOBT, yet those living further away had a lower likelihood. A consideration for this disparate finding is 28% of urban veterans live > 90 minutes from a VAMC. Thus, travel distance may trump rural residence as a mitigating factor in accessing follow-up. Impacts: Future research should help disentangle travel time from rural residence and the impact each has upon access. Because GI specialty services are limited to VAMCs, novel ways to provide these services to veterans living further away should be engaged.