Introduction
Colorectal cancer (CRC) is a leading cause of cancer-related deaths in the US, and underinsured patients continue to have higher incidence and mortality rates. This disparity, further exacerbated by the COVID-19 pandemic, is largely due to inadequate access to screening colonoscopies. To mitigate this inequity, we conducted a quality improvement study to investigate how the implementation of a patient navigator impacted adult colonoscopy wait times for underinsured patients at a tertiary academic medical center.

Methods
A total of 3,403 routine (screening and surveillance) and 1,896 diagnostic colonoscopies were reviewed across 5 intervals – 2019, 2020, 2021, May 2022 – October 2022, and November 2022 – May 2023. Patients were divided into two panels based on insurance status: “insured” (Commercial, Medicare, Managed Medicaid), and “underinsured” (Self-Pay, Medicaid, Emergency Medicaid). An institutional research award funded a bilingual patient navigator who conducted patient reminder calls and rescheduled procedures to fill cancelled slots during May 2022 – October 2022 and November 2022 – May 2023. Wait times were defined as the number of days between the initial clinic visit and the colonoscopy. Multivariable regression analyses were conducted for the primary outcomes of routine and diagnostic colonoscopy wait times.

Results
Baseline analysis revealed that wait times for diagnostic colonoscopies after 2019, as well as wait times for routine colonoscopies after 2020, were significantly longer for the underinsured compared to the insured panel. For routine colonoscopies, the difference in wait times during November 2022 – May 2023 was reduced by 33.39 days when compared to 2021 (95% CI: 10.31 – 56.47) and 58.10 days when compared to May 2022 – October 2022 (95% CI: 36.30 – 79.90). For diagnostic colonoscopies, the corresponding wait time reductions were 28.82 days (95% CI: 11.20 – 46.44) and 20.17 days (95% CI: 0.77 – 39.58), respectively. Furthermore, during November 2022 – May 2023, the difference in routine colonoscopy wait times between the underinsured and insured panels reached insignificance (0.44 days, 95% CI: -14.27 – 15.15), and did not differ significantly from the 2019 pre-pandemic wait time difference. A significant difference in diagnostic wait times continued during November 2022 – May 2023 (18.13 days, 95% CI: 3.93 – 32.33), however, it no longer differed from the 2019 pre-pandemic wait time difference (Figure 1 & Table 1).

Conclusion
Disparities in routine and diagnostic colonoscopy wait times were drastically reduced following implementation of a patient navigator for underinsured patients, and successfully mitigated the impact of the COVID-19 pandemic. Monitoring of colonoscopy wait times as a quality metric and developing targeted interventions are essential for the advancement of health equity.

<b>Figure 1.</b> Estimated differences in wait time between underinsured and insured patients within each time period for <b>(a)</b> routine and <b>(b)</b> diagnostic colonoscopies. Data points in red indicate wait time differences that are statistically significant (p < 0.05).

Figure 1. Estimated differences in wait time between underinsured and insured patients within each time period for (a) routine and (b) diagnostic colonoscopies. Data points in red indicate wait time differences that are statistically significant (p < 0.05).

<b>Table 1. </b>Estimated change in average routine and diagnostic colonoscopy wait time differences between underinsured and insured patients across time intervals. Data points in red indicate statistically significant changes in wait time difference (p < 0.05).

Table 1. Estimated change in average routine and diagnostic colonoscopy wait time differences between underinsured and insured patients across time intervals. Data points in red indicate statistically significant changes in wait time difference (p < 0.05).

Ricardo Flores

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