Improving Colorectal Cancer Screening in the West Oahu Community of Hawaii
Date
2025
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Abstract
Introduction: Colorectal cancer (CRC) is the third most common cause of cancer-related mortality in Hawaii (1). Only 65% of Hawaii’s population between ages 45 and 75 has been screened for CRC (2), which is below the American Cancer Society National Colorectal Cancer Roundtable goal of 80% (3). Similarly, we found the screening rate in the population attributed to a large primary care practice in West Oahu to be low at 45%.
Objective: Identify root causes for low CRC screening rates and test possible interventions to improve screening rates in this population.
Method: First, we interviewed and observed the primary care team to understand their current workflows for both patient in-reach and outreach. Second, chart reviews of the electronic medical records (EMR) of 388 patients covered by Hawaii Medical Service Association (HMSA) insurance at this primary care office were conducted to include patients who were deemed at “average risk” for CRC. Patients were excluded from the root cause analysis if they were at “high-risk” for CRC (e.g., family history of CRC, past medical history of CRC, history of inflammatory bowel disease, familial adenomatous polyposis, Lynch syndrome, past colectomy, or past radiation to pelvis), since these high-risk patients required a different workflow and made up a very small percentage of the population.
Third, Plan-Do-Study-Act (PDSA) cycles were then conducted over two months with the intent of targeting the most common root causes. The first cycle standardized electronic orders for the Fecal Immunochemical Test (FIT). The second cycle utilized a HIPAA-compliant text-messaging outreach tool to notify patients who were due for CRC screening. The third cycle focused on calling patients who could not be reached via text. Chart reviews were conducted throughout all PDSA cycles to measure changes in screening rates.
Results:
Baseline screening rate was 45% (314 adherent patients out of 702 eligible HMSA patients). After chart review, 74 additional patients were found to be adherent and 14 high-risk patients were excluded, increasing the screening rate to 57%. The most common reason for this 12% increase was a discrepancy between insurance claims data and EMR data. For the remaining unscreened patients, the most common reason for care gaps was a lack of standardized workflows for addressing CRC screening gaps during in-office visits.
Discussion:
Close collaboration with the office staff was crucial for implementing and facilitating PDSA cycles. Focusing on patient outreach uncovered social determinants of health affecting the clinic’s population, such as transportation and financial difficulties. Future incorporation of these projects into the JABSOM curriculum can provide an opportunity for students to apply populational health concepts in a clinical setting.
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