Faculty Bibliography

GOALS/BACKGROUND/OBJECTIVE:Patients who "no-show" for colonoscopy or present with poor bowel preparation waste endoscopic resources and do not receive adequate examinations for colorectal cancer (CRC) screening. Using the Health Belief Model, we modified an existing patient education pamphlet and evaluated its effect on nonattendance rates and bowel preparation quality. STUDY/METHODS:We implemented a color patient education pamphlet to target individual perceptions about CRC and changed bowel preparation instructions to include a low-residue diet instead of the previous clear liquid diet. We compared the nonattendance rate over a 2-month period before and after the introduction of the pamphlet, allowing for a washout period during which pamphlet use was inconsistent. We compared the Boston Bowel Preparation Scale (BBPS) in 100 consecutive patients who underwent colonoscopy during each of the 2 periods. RESULTS:Baseline characteristics between the 2 groups were similar, although patients who received the pamphlet were younger (P=0.03). The nonattendance rate was significantly lower in patients who received the pamphlet (13% vs. 21%, P=0.01). The percentage of patients with adequate bowel preparation increased from 82% to 86% after introduction of the pamphlet, although this was not statistically significant (P=0.44). The proportion of patients with a BBPS score of 9 was significantly higher in the pamphlet group (41% vs. 27%, P=0.03). There was no difference in adenoma and sessile serrated adenoma detection rates before and after pamphlet implementation. CONCLUSIONS:After implementing a theory-based patient education intervention with a low-residue diet, our absolute rate for colonoscopy nonattendance decreased by 8% and the proportion of patients with a BBPS score of 9 increased by 14%. The Health Belief Model appears to be a useful construct for CRC screening interventions.

Bowel preparation with low-residue diet (LRD) has resulted in higher patient satisfaction and similar polyp detection rates compared to conventional clear liquid diet. However, there is limited experience with LRD in veterans, in whom conditions associated with poor bowel preparation are more prevalent than the general population. To examine risk factors associated with inadequate bowel preparation, we conducted a chart review of outpatient colonoscopies at the Manhattan VA Medical Center from February 2017 to April 2018. To examine patient satisfaction and compliance, we administered an anonymous questionnaire to patients undergoing outpatient colonoscopy from March to August 2018. Patients assessed by chart review (n = 660) were 92% male with a mean age of 64 years. An adequate Boston Bowel Preparation Scale score ≥2 in each colonic segment was achieved in 94% of procedures. Higher BMI, diabetes, prior inadequate bowel preparation, bowel preparation duration of two days, and opioid use were associated with inadequate bowel preparation on univariable analysis. On multiple logistic regression, only higher BMI remained a predictor, with every one-unit increase associated with a 6% increased odds of poor bowel preparation. Questionnaire responses showed 84% of patients were willing to repeat LRD bowel preparation, 85% found the process easy or acceptable, and 78% reported full adherence to LRD. These findings demonstrate that bowel preparation quality, patient satisfaction, and compliance were all high among veterans using LRD.

INTRODUCTION: Screening for colorectal cancer (CRC) reduces incidence and mortality. Latinos are more likely to be diagnosed with late-stage CRC than non-Latino whites, a disparity that may be partially attributed to lower rates of screening among Latinos. New York City (NYC) has the fourth largest Latino population in the U.S., with Dominicans comprising the largest subgroup (41%). The current study examines predictors of up-to-date colonoscopy use among Dominicans using the NYC Community Health Survey (NYCCHS).
METHOD(S): The NYCCHS is an annual population-based telephone survey of New Yorkers aged 18 and older. We included all Dominicans aged 50 and older who participated in the survey from 2003-2016. The outcome of interest was up-to-date colonoscopy use, defined as having completed a colonoscopy within the past 10 years. To evaluate sociodemographic and medical predictors of colonoscopy uptake, we entered age, sex, and all factors with P< 0.10 on univariate analysis into multivariable models for each of four consecutive time periods: 2003-2008, T1; 2009-2012, T2; 2013-2014, T3; and 2015-2016, T4. The final models were determined using stepwise backward selection.
RESULT(S): Results for 3,237 Dominican participants are shown in Table 1. On multivariable analysis, two variables were significantly associated with colonoscopy use in three of the time periods: age >=65 (T1, T2, T4) and having received a flu vaccine in the prior year (T1, T3, T4). Two variables were significantly associated with colonoscopy uptake in two time periods: foreign birth (T1, T4) and longer duration of residence in the US (T2, T3). Variables associated with up-to-date colonoscopy use in only one time period included having a primary care provider (T2), being unemployed (T2), self-rated poor health status (T2), residence in Queens (T3), and not drinking sugar-sweetened beverages (T3).
CONCLUSION(S): Among Dominicans living in NYC, older age, foreign birthplace, longer duration of residence in the US, and receiving the flu vaccine were the most consistent factors associated with upto- date colonoscopy use. (Table Presented)

INTRODUCTION: Colorectal cancer (CRC) is a leading cause of cancer death among Asian Americans, who also have one of lowest rates of CRC screening. Chinese Americans are the largest Asian American subgroup in the United States (US), but there is a paucity of data examining predictors of CRC screening in this population. We used the New York City Community Health Survey (NYCCHS) to study factors associated with up-to-date colonoscopy use among Chinese Americans.
METHOD(S): The NYCCHS is an annual population-based telephone survey. For this analysis, we included all Chinese Americans aged >=50 years who participated in the survey from 2003-2016. We calculated up-to-date CRC screening uptake by colonoscopy, defined as colonoscopy within the last 10 years. To evaluate sociodemographic and medical predictors of colonoscopy use over four consecutive time periods, we entered age, sex, and any additional factors with P< 0.10 on univariate analysis into a multivariable model and reached the final model for each period using stepwise backward selection.
RESULT(S): During the study period, 2,577 Chinese Americans were surveyed and 62.4% had received a colonoscopy within 10 years. On multivariable analysis, receiving a flu shot was the only consistent positive predictor of up-to-date colonoscopy use from 2009-2016 (OR 2.06-2.36, Table 1). Individuals without a primary care provider were less likely to have received a colonoscopy from 2003-2012 (OR 0.25-0.42), and the risk estimate remained consistent but was no longer statistically significant from 2015-2016. Similarly, being born outside of the US was associated with lower colonoscopy uptake from 2009-2014 (OR 0.06-0.22). Compared to never smokers, current but not former smokers were significantly less likely to have received up-to-date colonoscopy (OR 0.37 in 2003-2008; OR 0.16 in 2013-2014). Age, sex, borough of residence, and exercise activity were not consistent predictors of up-to-date colonoscopy uptake.
CONCLUSION(S): Among Chinese Americans older than age 50 living in NYC, those who had a primary care provider and received annual flu shots were most likely to be up-to-date with colonoscopy. Foreign-born Chinese Americans and current smokers were less likely to have received colonoscopy. These findings highlight the importance of primary care for CRC prevention and provide insight into the vulnerable populations within the Chinese American community

INTRODUCTION: Colorectal cancer (CRC) is the third most prevalent cancer and the third leading cause of cancer death for women and men in the United States. There is emerging evidence that the gut microbiome plays a role in CRC development, and antibiotics are one of the most common exposures that can alter the gut microbiome. We performed a systematic review and meta-analysis to characterize the association between antibiotic use and colorectal neoplasia risk.
METHOD(S): We searched Pubmed, EMBASE, and Web of Science for articles describing the relationship between antibiotic exposure and colorectal neoplasia (cancer or adenoma) through October 2018. A total of 5342 citations were identified, which were reviewed independently by two investigators. After screening, we evaluated 15 articles and included 5 in the final analysis. We assessed the association between any antibiotic use as well as intensity of antibiotic use (defined as number of courses or duration of therapy) and colorectal neoplasia risk. Random effects metaanalysis was performed.
RESULT(S): Four studies provided five estimates for the association between any antibiotic use and risk of colorectal neoplasia. There was a 4% increased risk of neoplasia among individuals exposed to antibiotics (RR 1.04, 95% CI 1.02-1.07, Figure 1), with no evidence of heterogeneity (P=0.96, I²=0%). Five studies provided 13 estimates of the association between antibiotic intensity and colorectal neoplasia. Individuals with the highest intensity of antibiotic exposure had a 13% higher risk of colorectal neoplasia than those with lowest exposure (RR 1.13, 95% CI 1.06-1.21, Figure 2). However, significant heterogeneity was observed (P=0.04, I²=45%). Given the small number of studies, subgroup analyses on antibiotic class could not be performed.
CONCLUSION(S): Antibiotic exposure is associated with a subsequent increased risk of colorectal neoplasia. Furthermore, this relationship appears to be dose-dependent. Given the widespread use of antibiotics in childhood and early adulthood, additional research to further characterize this relationship is needed. (Figure Presented)

INTRODUCTION: Colorectal cancer (CRC) is a leading cause of cancer death among Hispanic Americans. Puerto Ricans are the second largest Hispanic subgroup in the United States and the largest in New York City, but little is known about predictors of CRC screening uptake in this population. We used the New York City Community Health Survey (NYCCHS), a population-based telephone survey, to investigate predictors of up-to-date colonoscopy use over time among Puerto Ricans aged >=50 in NYC.
METHOD(S): We assessed the association between sociodemographic and medical factors and up-to-date colonoscopy use (defined as colonoscopy in the last 10 years) over four time periods: 2003-2008, 2009-2012, 2013-2014, and 2015-2016.We entered age, sex, and any additional factors with P<0.10 on univariate analysis into a multivariable model and reached the final model for each period using stepwise backward selection.
RESULT(S): On univariate analysis, factors including age >=65, having a primary care provider, and receiving the flu shot were associated with colonoscopy use in the last 10 years. After adjusting for multiple sociodemographic and medical factors (Table 1), age >=65 [OR 1.41 (2003-2008), OR 1.76 (2013-2014), OR 1.82 (2015-2016)] and receiving the flu shot [OR 2.14 (2003-2008), OR 1.52 (2009- 2012), OR 1.95 (2013-2014), OR 1.62 (2015-2016)] were two factors positively associated with up-todate colonoscopy use over most time periods. Those without a primary care provider [OR 0.53 (2003- 2008), OR 0.38 (2013-2014)] were significantly less likely to have an up-to-date colonoscopy.
CONCLUSION(S): Older age, having a primary care provider, and receiving the flu shot are independent predictors of up-to-date colonoscopy use among Puerto Ricans in NYC. Targeted interventions to improve CRC screening should be considered for Puerto Ricans aged 50-64 and those who do not have a primary care provider. (Figure Presented)

INTRODUCTION: Screening decreases colorectal cancer (CRC) incidence and mortality, but uptake in the United States remains suboptimal at 62%. Prior studies have investigated the effect of various interventions on overall CRC screening and stool-based testing, but the effect on colonoscopy-the predominant screening test in the US-has not been fully examined. We performed a systematic review and meta-analysis to assess the effect of behavioral interventions on screening colonoscopy uptake.
METHOD(S): We searched PubMed, EMBASE, and Cochrane databases through June 2018 for controlled trials that assessed the effect of behavioral interventions on screening colonoscopy rates. Our search yielded a total of 6,952 titles. All abstracts and articles were screened by at least two independent reviewers and 54 manuscripts were selected for review. Relative risk estimates were extracted from the original article or calculated from the raw data. The primary outcome was the relative increase in screening colonoscopy completion with any behavioral intervention. Subgroup analysis by type of intervention was also performed. Random effects meta-analysis was performed using Stata.
RESULT(S): A total of 21 studies with 24 behavioral interventions were analyzed. The most common interventions were patient navigation (n=8), a combination of multiple interventions (n=7), and educational interventions (n=4). Overall, behavioral interventions increased colonoscopy completion by 58% compared to controls (OR 1.58, 95% CI 1.33-1.88, Figure). Patient navigation (OR 1.80, 95% CI 1.22-2.67) and multiple interventions (OR 1.70, 95% CI 1.15- 2.50) had the strongest effect on colonoscopy completion. Significant heterogeneity was observed both overall and by intervention type, which may be attributed to differences in study setting and control group selection.
CONCLUSION(S): Behavioral interventions increase screening colonoscopy completion and should be considered in clinical practice. In particular, patient navigation and multiple interventions are the best-studied and most effective interventions. (Figure Presented)

BACKGROUND & AIMS/OBJECTIVE:Disparities in colorectal cancer (CRC) screening uptake by race/ethnicity, socioeconomic status, and geography are well documented. We sought to further characterize the relationship between sociodemographic factors and up-to-date colonoscopy use in a diverse urban center using the 2014 New York City Community Health Survey (NYCCHS). METHODS:We examined overall colonoscopy uptake by race/ethnicity-with a particular interest in Asian and Hispanic subgroups-and used weighting to represent the entire 2014 NYC adult population. We also evaluated the association between 10 sociodemographic variables (age, sex, race/ethnicity, birthplace, home language, time living in the US, education, employment, income, and borough of residence) and colonoscopy use using univariable and multivariable logistic regression models. RESULTS:Up-to-date colonoscopy uptake was 69% overall with reported differences by racial/ethnic group, ranging from 44%-45% for Mexicans and Asian Indians to 75% for Dominicans. In the multivariable regression model, colonoscopy use was associated with age greater than 65 years, Chinese language spoken at home, and not being in the labor force. Lower colonoscopy use was associated with living in the US for less than 5 years, Asian Indian language spoken at home, lower income, and residing outside of Manhattan. CONCLUSIONS:Among New Yorkers older than age 50, up-to-date colonoscopy use varied significantly by race/ethnicity, especially in Asian and Hispanic subgroups. Recent immigrants, low-income groups, and those living outside of Manhattan were significantly less likely to receive CRC screening. Targeted interventions to promote CRC screening in these underserved groups may improve overall screening uptake.