The role of health, sociodemographic, and care delivery factors in timely completion of colonoscopy in a US-based primary care population: a retrospective analysis

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DesRoches, Russell S. Phillips, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7861275/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 15 Jan, 2026 Read the published version in BMC Gastroenterology → Version 1 posted 14 You are reading this latest preprint version Abstract Background Timely colonoscopy completion in primary care can prevent diagnostic delays in colorectal cancer. Factors that influence why patients experience timely or delayed colonoscopy completion are unclear. We sought to identify potentially intervenable factors associated with earlier (or later) colonoscopy test completion in primary care. Methods All colonoscopy orders placed by primary care clinicians in two clinics within a single hospital system between January 1 2018 and December 31 2021 were examined for time to completion using Cox Proportional Hazards Model, where the hazards of completion were adjusted for variables potentially associated with the outcome, including sociodemographic, individual health-related, and care delivery factors. Results Among 10,576 colonoscopy tests ordered, 56% were completed within one year. After multivariable adjustment, earlier colonoscopy completion was associated with receiving care at a community health center, preferred spoken language other than English, male sex, Black race, any college education, a diagnosis of rectal bleeding, and documented use of an electronic patient portal. Completion occurred later among patients with Medicaid insurance, subsidized commercial insurance, or depression, and among patients whose tests were ordered by a nurse practitioner or a resident, or during a telehealth appointment. Results were similar for a sensitivity analysis restricted to those patients within a Medicaid ACO, except for the finding that Black race was no longer associated with test completion. Conclusions Based on our findings, certain factors associated with –early or delayed- colonoscopy test completion lend themselves to possible interventions. Targeted care navigation (e.g. reminder calls, assisted scheduling, transportation assistance) may be needed for patients whose colonoscopy tests are ordered at telehealth appointments or by NPs or residents, or who have certain insurance types (e.g. Medicaid and high-deductible insurance). Harnessing strategies used at community health centers to improve culturally competent test scheduling may also be a promising area of future work to help patients book and attend colon cancer test appointments. More study is needed to understand the observed relationship between electronic portal use and test completion and why some patient characteristics such as non-English preference are associated with earlier completion of ordered tests in our study. Colonoscopy diagnostic delay primary care Figures Figure 1 Background Differences in colorectal cancer (CRC) outcomes according to population characteristics are well documented ( 1 – 4 ), although the mechanisms remain unclear ( 5 ). Delayed or missing cancer screening and delayed treatment have been repeatedly associated with worse CRC outcomes ( 6 – 8 ). As part of a larger study focused on improving diagnostic loop closure, we sought to understand the factors associated with earlier or later completion of ordered colonoscopies (screening and diagnostic) among primary care patients within a single hospital system in the United States (US). We explored whether certain sociodemographic, health, and care delivery factors were positively or negatively associated with time to colonoscopy completion. We suggest future interventions and investigations to improve timely completion of colorectal cancer tests within US-based primary care. Methods To assess factors associated with timeliness of colonoscopy completion, we included patients who had colonoscopy orders placed by primary care clinicians at a hospital-based practice or a community health center practice (CHC) –both in the same US-based hospital system- between January 1, 2018, and December 31, 2021. Colonoscopy tests ordered less than one year prior to the date of last follow up (February 12, 2022) were excluded from analysis to ensure sufficient observation time. In the primary analysis, we used Cox proportional hazards models to assess factors associated with time to colonoscopy completion. Incomplete colonoscopy orders were administratively censored at the end of the period of observation (February 12, 2022). Models were adjusted for sociodemographic (insurance type, highest education level, ethnicity, language, race), health-related (age, sex, depression diagnosis, health complexity, rectal bleeding diagnosis, electronic patient portal use), and care delivery factors (practice site, visit modality, ordering clinician, and ordered during the COVID pandemic -defined as March 1, 2020 through December 31, 2021). In addition to the primary analysis, we performed a sensitivity analysis in a subgroup of Medicaid ACO patients -whose insurance requires tests to be completed within the hospital system - to assess the effect of unmeasured confounders in the insurance type category, and to exclude the possibility of colonoscopy completion outside the hospital system. We report hazard ratios (HRs) with 95% confidence intervals (CIs). Results Among 10,576 colonoscopy tests ordered from 2018 to 2021, 44% of colonoscopies were not completed within a year after ordering. Table 1 summarizes the population characteristics. Table 2 presents adjusted hazard ratios (HRs) from the Cox models. [Table 1 ] [Table 2 ] Table 1 Baseline Characteristics of the Study Population Factor Category Main Analysis Population N (%) Sensitivity Analysis Population N (%) Total Population 10,576 1,257 Age (Mean, SD) a 59.39 (10.47) 55.94 (8.89) Sex Female 5,565 (52.6) 754 (60.0) Male 5,011 (47.4) 503 (40.0) English Language Yes 9,159 (86.6) 791 (62.9) No 1,378 (13.0) 457 (36.4) Missing b 39 (0.4) 9 (0.7) Race White 5,885 (55.6) 358 (28.5) Asian 524 (5.0) 76 (6.0) Black 3,081 (29.1) 574 (45.7) Other 672 (6.4) 172 (13.7) Missing b 414 (3.9) 77 (6.1) Hispanic No 9,066 (85.7) 1,015 (80.7) Yes 915 (8.7) 174 (13.8) Missing b 595 (5.6) 68 (5.4) Insurance k Commercial 5,670 (53.6) - Medicaid only 1,257 (11.9) - Medicare only 2,750 (26.0) - Medicare and Medicaid 358 (3.4) - Other 160 (1.5) - Subsidized commercial 381 (3.6) - Education c High school or less 4,328 (40.9) 790 (62.8) Greater than high school 4,946 (46.8) 297 (23.6) Missing b 1,302 (12.3) 170 (13.5) Depression d No 8,559 (80.9) 932 (74.1) Yes 2,017 (19.1) 325 (25.9) Charlson Comorbidity Score e 0 5,652 (53.4) 637 (50.7) 1–2 3,038 (28.7) 367 (29.2) 3–4 971 (9.2) 129 (10.3) 5 or higher 915 (8.7) 124 (9.9) Colonoscopy Ordered By f Attending 8,542 (80.8) 878 (69.8) Nurse Practitioner 448 (4.2) 58 (4.6) Resident 1,586 (15.0) 321 (25.5) Portal Use g No 7,084 (67.0) 1,091 (86.8) Yes 3,492 (33.0) 166 (13.2) Colonoscopy Ordered During COVID h No 7,322 (69.2) 878 (69.8) Yes 3,254 (30.8) 379 (30.2) Index Visit Modality i In person 8,158 (77.1) 1,010 (80.4) Telephone 705 (6.7) 100 (8.0) Video 293 (2.8) 12 (1.0) Missing b 1,420 (13.4) 135 (10.7) Rectal Bleeding j Yes 574 (5.4) 88 (7.0) No 9,991 (94.5) 1,167 (92.8) Missing b 11 (0.1) 2 (0.2) Practice Site Community Health Center 1,269 (12.0) 367 (29.2) Hospital-based practice 9,307 (88.0) 890 (70.8) Colonoscopy Completion in 1 Year l No 4,628 (43.8) 624 (49.6) Yes 5,948 (56.2) 633 (50.4) a. SD denotes standard deviation. b. Missing refers to the absence of data in the electronic health record. c. Patients without education data were coded as “missing" Those with a high school diploma or less were categorized as "high school or below", and all others as "greater than high school.” d. Depression was defined using ICD-10 codes (F32.xx-F33.xx). e. Charlson Co-morbidity Index ( 12 ) was calculated from billing diagnoses for all encounters within 2 years of the index referral date. Patients were classified into 3 categories based on their score: 0, 1–2,>=3. f. Colonoscopy orders were placed by attending physicians, nurse practitioners, and residents. g. Patient portal use was defined as registration on the patient site and viewing at least one note. h. We defined colonoscopy ordering during COVID as colonoscopy ordered between March 1st, 2020 and December 31st, 2021. i. Visit modality was separated into in-person, video, or telephone. j. Rectal bleeding was defined using ICD-10 codes (K62.5, K92.2, K51.911). k. ‘Medicare’ includes all Medicare products (Advantage and traditional). ‘Medicaid’ includes all Masshealth products including Masshealth ACO, Masshealth Limited, and Masshealth Standard. ‘Commercial’ includes all HMO and PPO insurance plans excluding Medicare Advantage plans and subsidized “Connector” plans (i.e. ‘Subsidized’). ‘Medicare/Medicaid’ includes those with dual coverage. ‘Other’ includes all other plans not falling into above categories. l. Colonoscopy completion in 1 year was defined as completion within 365 days of ordering Table 2 Adjusted Hazard Ratios (HRs) for Colonoscopy Completion Factor Main Analysis HR (95% CI) Sensitivity Analysis HR (95% CI) Age a 1.00 [0.96, 1.05] 1.00 [0.99, 1.02] Sex Female (Reference) 1.00 1.00 Male 1.09 [1.03, 1.14] 1.00 [0.85, 1.17] Hispanic No (Reference) 1.00 1.00 Yes 1.01 [0.91, 1.12] 0.94 [0.74, 1.20] Missing b 0.91 [0.80, 1.03] 0.53 [0.32, 0.87] Education c High school or less (Reference) 1.00 1.00 Greater than high school 1.07 [1.01, 1.14] 1.18 [0.97, 1.44] Missing b 1.01 [0.93, 1.10] 0.97 [0.75, 1.24] Depression d No (Reference) 1.00 1.00 Yes 0.95 [0.89, 1.01] 0.92 [0.76, 1.10] Charlson Comorbidity Score e 0 (Reference) 1.00 1.00 1–2 1.00 [0.94, 1.06] 0.95 [0.80, 1.13] 3–4 1.04 [0.95, 1.13] 0.88 [0.67, 1.15] 5 or higher 0.93 [0.84, 1.02] 0.77 [0.58, 1.03] Colonoscopy Ordered By f Attending (Reference) 1.00 1.00 Nurse Practitioner 0.77 [0.68, 0.88] 0.92 [0.63, 1.35] Resident 0.92 [0.85, 0.99] 1.08 [0.89, 1.31] Patient Portal Use g No (Reference) 1.00 1.00 Yes 1.19 [1.13, 1.26] 1.03 [0.81, 1.32] Colonoscopy Ordered During COVID h No (Reference) 1.00 1.00 Yes 0.93 [0.87, 0.99] 1.08 [0.90, 1.31] Index Visit Modality i In person (Reference) 1.00 1.00 Telephone 0.56 [0.49, 0.64] 0.52 [0.35, 0.75] Video 0.76 [0.63, 0.90] 0.66 [0.27, 1.63] Missing b 1.15 [1.07, 1.24] 1.10 [0.85, 1.42] Rectal Bleeding j No (Reference) 1.00 1.00 Yes 1.88 [1.69, 2.08] 1.65 [1.24, 2.20] Missing 1.46 [0.69, 3.07] 4.19 [1.03, 17.11] Race White (Reference) 1.00 1.00 Asian 1.02 [0.90, 1.14] 1.06 [0.76, 1.48] Black 1.08 [1.02, 1.16] 0.98 [0.80, 1.20] Other 1.03 [0.91, 1.16] 1.06 [0.81, 1.40] Missing b 0.91 [0.78, 1.07] 0.95 [0.61, 1.50] Insurance k Commercial (Reference) 1.00 — Medicaid 0.82 [0.75, 0.89] — Medicare 1.01 [0.94, 1.08] — Medicare and Medicaid 0.86 [0.74, 0.99] — Other 0.63 [0.50, 0.79] — Subsidized 0.80 [0.69, 0.91] — Practice Site Hospital-based practice (Reference) 1.00 1.00 Community Health Center 1.13 [1.03, 1.24] 1.32 [1.07, 1.62] English Language Yes (Reference) 1.00 1.00 No 1.23 [1.12, 1.34] 1.16 [0.95, 1.41] Missing b 0.77 [0.46, 1.27] 1.03 [0.37, 2.85] a. SD denotes standard deviation. b. Missing refers to the absence of data in the electronic health record. c. Patients without education data were coded as “missing" Those with a high school diploma or less were categorized as "high school or below", and all others as "greater than high school.” d. Depression was defined using ICD-10 codes (F32.xx-F33.xx). e. Charlson Co-morbidity Index ( 12 ) was calculated from billing diagnoses for all encounters within 2 years of the index referral date. Patients were classified into 3 categories based on their score: 0, 1–2, >=3. f. Colonoscopy orders were placed by attending physicians, nurse practitioners, and residents. g. Patient portal use was defined as registration on the patient site and viewing at least one note. h. We defined colonoscopy ordering during COVID as colonoscopy ordered between March 1st, 2020 and December 31st, 2021. i. Visit modality was separated into in-person, video, or telephone. j. Rectal bleeding was defined using ICD-10 codes (K62.5, K92.2, K51.911). k. ‘Medicare’ includes all Medicare products (Advantage and traditional). ‘Medicaid’ includes all Masshealth products including Masshealth ACO, Masshealth Limited, and Masshealth Standard. ‘Commercial’ includes all HMO and PPO insurance plans excluding Medicare Advantage plans and subsidized “Connector” plans (i.e. ‘Subsidized’). ‘Medicare/Medicaid’ includes those with dual coverage. ‘Other’ includes all other plans not falling into above categories. l. Colonoscopy completion in 1 year was defined as completion within 365 days of ordering. In the primary analysis using a Cox proportional hazards model, earlier completion of colonoscopy was associated with several factors - higher education, non-English language preference, Black race, male sex, rectal bleeding diagnosis, electronic patient portal use, and care at the community health center practice. Compared to female patients, male patients were more likely to complete colonoscopy earlier (HR 1.09, 95% CI [1.03, 1.14]). Non-English-speaking patients were also more likely to complete colonoscopy earlier than English speakers (HR 1.23, 95% CI [1.12, 1.34]). Black patients were more likely than White patients to complete colonoscopy earlier (HR 1.08, 95% CI [1.02, 1.16]). Patients with rectal bleeding and those using the patient portal had a substantially higher likelihood of earlier completion (HR 1.88, 95% CI [1.69, 2.08] and HR 1.19, 95% CI [1.13, 1.26], respectively). Similarly, patients receiving care at the community health center practice were significantly more likely to complete colonoscopy earlier than those seen in the hospital-based practice (HR 1.13, 95% CI [1.03, 1.24]), as shown in Fig. 1 , which displays unadjusted cumulative probability of completing a colonoscopy test during the period of follow-up by practice setting (p < 0.01). [Figure 1 ] By contrast, orders placed by nurse practitioners (HR 0.77, 95% CI [0.68, 0.88]) or residents (HR 0.92, 95% CI [0.85, 0.99]) were associated with later completion compared to those placed by attending physicians. Compared to patients with commercial insurance, later test completion was observed for those with Medicaid (HR 0.82, 95% CI [0.75, 0.89]), dual coverage (Medicaid and Medicare) (HR 0.86, 95% CI [0.74, 0.99]), or subsidized commercial insurance (HR 0.80, 95% CI [0.69, 0.91]). Additionally, colonoscopies ordered during the COVID pandemic were more likely to be completed later than those ordered before the pandemic (HR 0.93, 95% CI [0.87, 0.99]). The sensitivity analysis results (i.e. Medicaid ACO patients only) are consistent in directionality with those of the primary analysis, with the exception that Black race is no longer significant for earlier colonoscopy completion. Discussion From 2018 to 2021 in this US-based system, 56% of 10,576 colonoscopies ordered in primary care were completed within one year, indicating a need for primary care-based interventions to improve timely colonoscopy completion as has been discussed elsewhere (9, 11). For patients in our cohort who completed their colonoscopy during the period of follow up, several unique factors that modify the rate of completion can inform future interventions and research. For instance, earlier colonoscopy completion among CHC patients -adjusted for race, language, ethnicity and education- compared to patients seen at a hospital-based practice is a novel finding. We hypothesize that this finding relates to organizational cultural competency at the CHC that historically has provided enhanced support, reminders, and instruction around colonoscopy scheduling and completion compared to the hospital-based primary care practice. Patient navigation was demonstrated to be an effective strategy to increase colonoscopy test completion in select high risk populations (13). Understanding and describing how CHCs intentionally support and help patients navigate the process of getting a diagnostic test can delineate best practices to guide other primary care sites. The slower completion of colonoscopy tests when ordered at phone and video appointments or by NPs or resident MDs –as our research group has shown elsewhere for a range of test orders (10)- should prompt practices to enhance test coordination efforts –assisted scheduling, reminder calls- after virtual visits or when ordered by a NP or resident. We also observed that patients with subsidized –high deductible- commercial insurance completed tests much later than other commercial insurance types. This finding is in keeping with studies that have shown barriers to CRC screening among uninsured or underinsured patients (14), indicating a need for research to explore nuances in the relationship between health disparities and insurance status. Our focus on colonoscopy -screening and diagnostic- shapes and limits the implications of our findings. Although our analysis adjusted for rectal bleeding diagnosis to account for diagnostic colonoscopies ordered within our sample, we cannot otherwise reliably distinguish diagnostic from screening tests. Relying on EHR documentation of test completion (vs claims) in our sample could have missed tests completed outside the hospital system. We addressed this by examining the ACO Medicaid population separately, which showed consistent directionality with point estimates in the primary analysis, except for Black patients. The finding that Black patients had earlier test completion in the full analysis but not in the sensitivity analysis may reflect unmeasured confounders when controlling for insurance type or may be a function of the smaller sample size. Other types of colon cancer tests were not included in our dataset. Hence, the observation that non-English speakers are more likely to have earlier colonoscopy completion in our cohort may reflect factors influencing the likelihood of ordering a colonoscopy, as described elsewhere, including patient preference, provider bias, health literacy, availability of stool-based tests, and social support (15). More study is needed to understand the interconnected processes of colon cancer test selection and test completion, particularly among LEP populations. More studies are also needed to examine whether the positive relationship between patient portal use and earlier colonoscopy completion –as observed for other diagnostic testing loops (16)- is causal, or a proxy for patient activation. We are encouraged that a diagnosis of rectal bleeding is associated with earlier test completion, suggesting underlying system resiliency factors that can be instructive for improving colonoscopy test completion more generally. We recognize that timely colonoscopy completion is one of several mechanisms that account for population differences in colorectal cancer health outcomes. Earlier test completion for some may not translate into earlier treatment or greater survival, due to underlying risks that are independent of screening or prompt diagnosis (5). More research is needed to fill in the map of intervenable factors along the screening, diagnosis and treatment journey that optimize colorectal cancer outcomes. Conclusions The low rate (56%) of colonoscopy order completion within one year among primary care patients in a US-based hospital system underscores the need to identify, address, and harness factors that modify the timeliness of completion. Location of care (CHC practice), using an electronic patient portal, higher education, speaking a non-English language, and having a diagnosis of rectal bleeding were factors associated with earlier colonoscopy completion, whereas colonoscopy orders originating from a telehealth visit or ordered by a NP or resident and patients with depression, Medicaid, or subsidized commercial insurance had later completion. Some of these factors lend themselves to systems interventions, and some stimulate novel hypotheses for research efforts to improve timely colonoscopy completion. Abbreviations ACO Accountable Care Organization CHC Community Health Center CRC Colorectal cancer EHR Electronic health record HR Hazards ratio NP Nurse practitioner US United States Declarations Human Ethics and Consent to Participate declarations: Per regulation 45 CFR 46.104(d) (2)(2), consent to participate was not required for this study of retrospective anonymized data where no human subjects were included. Our study adheres to the Declaration of Helsinki with regard to research conducted on human data. The data used for this research was approved by the BIDMC Committee on Clinical Investigation (2020P000502). Consent for publication: Anonymized data was used in this study. Therefore, participant consent to publish was not necessary. Data availability: Datasets used for the analysis are available from the corresponding author upon reasonable request. Competing interests: The authors declare that they have no competing interests. Funding: Research was supported by AHRQ patient safety grant, R18HS027282. Authors’ contributions: TS, LF, RP, CD, and CZ jointly developed the research aim and methodology. CZ performed the Cox regression analyses and prepared Figure 1. TS and AZ conducted the historical data analysis. TS drafted the manuscript. LF, AZ, RP, CD, and CZ provided key edits and suggestions. Acknowledgements: We wish to acknowledge Umber Shafiq and Naing Aung who aided with dataset refinement. References Hollis RH, Chu DI. Healthcare Disparities and Colorectal Cancer. Surg Oncol Clin N Am. 2022 Apr;31(2):157-169. Epub 2022 Mar 8. McLeod MR, Galoosian A, May FP. Racial and Ethnic Disparities in Colorectal Cancer Screening and Outcomes. Hematol Oncol Clin North Am. 2022 Jun;36(3):415-428. Epub 2022 Apr 30. Liss DT, Baker DW. Understanding current racial/ethnic disparities in colorectal cancer screening in the United States: the contribution of socioeconomic status and access to care. 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National Survey of Patient Factors Associated with Colorectal Cancer Screening Preferences. Cancer Prev Res (Phila). 2021 May;14(5):603-614. Epub 2021 Apr 22. Bell SK, Amat MJ, Anderson TS, Aronson MD, Benneyan JC, Fernandez L, Ricci DA, Salant T, Schiff GD, Shafiq U, Singer SJ, Sternberg SB, Zhang C, Phillips RS. Do patients who read visit notes on the patient portal have a higher rate of "loop closure" on diagnostic tests and referrals in primary care? A retrospective cohort study. J Am Med Inform Assoc. 2024 Feb 16;31(3):622-630. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 15 Jan, 2026 Read the published version in BMC Gastroenterology → Version 1 posted Editorial decision: Revision requested 24 Nov, 2025 Reviews received at journal 21 Nov, 2025 Reviews received at journal 12 Nov, 2025 Reviewers agreed at journal 06 Nov, 2025 Reviewers agreed at journal 05 Nov, 2025 Reviews received at journal 31 Oct, 2025 Reviews received at journal 26 Oct, 2025 Reviewers agreed at journal 24 Oct, 2025 Reviewers agreed at journal 22 Oct, 2025 Reviewers invited by journal 22 Oct, 2025 Editor invited by journal 21 Oct, 2025 Editor assigned by journal 20 Oct, 2025 Submission checks completed at journal 17 Oct, 2025 First submitted to journal 17 Oct, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7861275","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":538249757,"identity":"b810d94e-0c69-4f94-981f-879670c62901","order_by":0,"name":"Talya Salant","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA+0lEQVRIiWNgGAWjYHACxgNAQs6AmcEASB+AiPEAhRtwqOeBKDMwJl1L4gYGYrXY8x9+cODnjj/p29mZt274wXBH3nxG8rMPbxhsZDccwGGLRJrBwd4zBrk7m9nKbvYwPDOccyPNeOYchjRj3FoYDA7wthnkbjjMY3abgeEw4wyeA8bMPAyHE3Fq4T/+4eDfNoN0A6gW+xk8xz8DtfzHrYUhx+Aw0JYEmJbEGew9IFsO4NZyI6fgsGybsSHELwaHk4FaihnnGCQbz8Shhb3/+MaHb9vk5M35D2+78aPisO0MZvbNDG8q7GT7cGhBAwYYjFEwCkbBKBgF5AAAl5tg0d1R6SQAAAAASUVORK5CYII=","orcid":"","institution":"Bowdoin St. Health Center","correspondingAuthor":true,"prefix":"","firstName":"Talya","middleName":"","lastName":"Salant","suffix":""},{"id":538249758,"identity":"7ae4454d-82de-480a-8019-b8e41c74e82b","order_by":1,"name":"Cancan Zhang","email":"","orcid":"","institution":"Beth Israel Deaconess Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Cancan","middleName":"","lastName":"Zhang","suffix":""},{"id":538249759,"identity":"3a45d56a-2794-4fb9-95be-f8a880d91184","order_by":2,"name":"Catherine M. DesRoches","email":"","orcid":"","institution":"Beth Israel Deaconess Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Catherine","middleName":"M.","lastName":"DesRoches","suffix":""},{"id":538249760,"identity":"1cd60ae1-b7dc-42c5-856d-402a8d0dbbc1","order_by":3,"name":"Russell S. Phillips","email":"","orcid":"","institution":"Beth Israel Deaconess Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Russell","middleName":"S.","lastName":"Phillips","suffix":""},{"id":538249761,"identity":"bca35959-cb0a-4d50-8256-b19edf8fd763","order_by":4,"name":"Leonor Fernandez","email":"","orcid":"","institution":"Beth Israel Deaconess Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Leonor","middleName":"","lastName":"Fernandez","suffix":""}],"badges":[],"createdAt":"2025-10-14 18:23:16","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7861275/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7861275/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12876-026-04612-z","type":"published","date":"2026-01-15T16:31:09+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":95007449,"identity":"3514be92-8cb6-47ad-aefb-f3461875b3b6","added_by":"auto","created_at":"2025-11-03 09:39:52","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":251275,"visible":true,"origin":"","legend":"","description":"","filename":"Colonoscopy.BMCgastroenterology.final.10.17.docx","url":"https://assets-eu.researchsquare.com/files/rs-7861275/v1/757c0e507aa0ec9134047437.docx"},{"id":95007445,"identity":"3349a272-c64d-4a31-a4be-38f1fb1fc77c","added_by":"auto","created_at":"2025-11-03 09:39:52","extension":"json","order_by":1,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":7829,"visible":true,"origin":"","legend":"","description":"","filename":"3f7298a104b643f49391b056192b5691.json","url":"https://assets-eu.researchsquare.com/files/rs-7861275/v1/cd7f1820d918c8c09d963570.json"},{"id":95221084,"identity":"673f1ffb-868a-46c1-9341-8bb3e3a27e17","added_by":"auto","created_at":"2025-11-05 16:18:12","extension":"xml","order_by":2,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":89592,"visible":true,"origin":"","legend":"","description":"","filename":"3f7298a104b643f49391b056192b56911enriched.xml","url":"https://assets-eu.researchsquare.com/files/rs-7861275/v1/52cf9271f1099970763c7e90.xml"},{"id":95007451,"identity":"2c020b11-330b-49dc-b5b2-a7bbad80bd43","added_by":"auto","created_at":"2025-11-03 09:39:52","extension":"jpeg","order_by":3,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":136439,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7861275/v1/c14889ee6bae9adb1d044057.jpeg"},{"id":95007444,"identity":"fc3fd261-7bb3-4af5-bf48-ffd3fb28b3a5","added_by":"auto","created_at":"2025-11-03 09:39:52","extension":"png","order_by":4,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":32368,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7861275/v1/821d77f8b112c7a3b0d12ca1.png"},{"id":95007447,"identity":"40b752b6-60d3-427b-b018-e168e3d91387","added_by":"auto","created_at":"2025-11-03 09:39:52","extension":"xml","order_by":5,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":87686,"visible":true,"origin":"","legend":"","description":"","filename":"3f7298a104b643f49391b056192b56911structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-7861275/v1/bdd18ddd4c669b5f9cc27f41.xml"},{"id":95007450,"identity":"15c3c0f4-aaf1-4cfc-b1f2-b71468763f2e","added_by":"auto","created_at":"2025-11-03 09:39:52","extension":"html","order_by":6,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":93194,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7861275/v1/4429c1e0c2137006f4d30426.html"},{"id":95007443,"identity":"0a76cc57-7603-454d-be0d-2e82eaceea96","added_by":"auto","created_at":"2025-11-03 09:39:52","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":81750,"visible":true,"origin":"","legend":"\u003cp\u003eTime to colonoscopy shown as cumulative probability, comparing the community health center and hospital-based practice\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003ea. p-value was obtained from the log-rank test.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7861275/v1/38d643e6c05bbb55c18f0316.png"},{"id":100614862,"identity":"5ea251b4-4e09-4649-821c-fb9357cd4cd7","added_by":"auto","created_at":"2026-01-19 17:26:42","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1083045,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7861275/v1/e3b8c4df-b08d-40f5-bb01-e0c9c50c5833.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"The role of health, sociodemographic, and care delivery factors in timely completion of colonoscopy in a US-based primary care population: a retrospective analysis","fulltext":[{"header":"Background","content":"\u003cp\u003eDifferences in colorectal cancer (CRC) outcomes according to population characteristics are well documented (\u003cspan additionalcitationids=\"CR2 CR3\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e), although the mechanisms remain unclear (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Delayed or missing cancer screening and delayed treatment have been repeatedly associated with worse CRC outcomes (\u003cspan additionalcitationids=\"CR7\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). As part of a larger study focused on improving diagnostic loop closure, we sought to understand the factors associated with earlier or later completion of ordered colonoscopies (screening and diagnostic) among primary care patients within a single hospital system in the United States (US). We explored whether certain sociodemographic, health, and care delivery factors were positively or negatively associated with time to colonoscopy completion. We suggest future interventions and investigations to improve timely completion of colorectal cancer tests within US-based primary care.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eTo assess factors associated with timeliness of colonoscopy completion, we included patients who had colonoscopy orders placed by primary care clinicians at a hospital-based practice or a community health center practice (CHC) \u0026ndash;both in the same US-based hospital system- between January 1, 2018, and December 31, 2021. Colonoscopy tests ordered less than one year prior to the date of last follow up (February 12, 2022) were excluded from analysis to ensure sufficient observation time.\u003c/p\u003e\u003cp\u003eIn the primary analysis, we used Cox proportional hazards models to assess factors associated with time to colonoscopy completion. Incomplete colonoscopy orders were administratively censored at the end of the period of observation (February 12, 2022). Models were adjusted for sociodemographic (insurance type, highest education level, ethnicity, language, race), health-related (age, sex, depression diagnosis, health complexity, rectal bleeding diagnosis, electronic patient portal use), and care delivery factors (practice site, visit modality, ordering clinician, and ordered during the COVID pandemic -defined as March 1, 2020 through December 31, 2021). In addition to the primary analysis, we performed a sensitivity analysis in a subgroup of Medicaid ACO patients -whose insurance requires tests to be completed within the hospital system - to assess the effect of unmeasured confounders in the insurance type category, and to exclude the possibility of colonoscopy completion outside the hospital system. We report hazard ratios (HRs) with 95% confidence intervals (CIs).\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eAmong 10,576 colonoscopy tests ordered from 2018 to 2021, 44% of colonoscopies were not completed within a year after ordering. Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e summarizes the population characteristics. Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e presents adjusted hazard ratios (HRs) from the Cox models. [Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e] [Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e]\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eBaseline Characteristics of the Study Population\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eFactor\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCategory\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMain Analysis Population N (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eSensitivity Analysis Population N (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eTotal Population\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e10,576\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e1,257\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eAge (Mean, SD)\u003c/em\u003e\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e59.39 (10.47)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e55.94 (8.89)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eSex\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n 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align=\"left\"\u003e\n \u003cp\u003e1,015 (80.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e915 (8.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e174 (13.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMissing\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e595 (5.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e68 (5.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eInsurance\u003c/strong\u003e\u003csup\u003ek\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCommercial\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e5,670 (53.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMedicaid only\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1,257 (11.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMedicare only\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2,750 (26.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMedicare and Medicaid\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e358 (3.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e160 (1.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSubsidized commercial\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e381 (3.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eEducation\u003c/strong\u003e\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHigh school or less\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4,328 (40.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e790 (62.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGreater than high school\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4,946 (46.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e297 (23.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMissing\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1,302 (12.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e170 (13.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eDepression\u003c/strong\u003e\u003csup\u003ed\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e8,559 (80.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e932 (74.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2,017 (19.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e325 (25.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eCharlson Comorbidity Score\u003c/strong\u003e\u003csup\u003ee\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e5,652 (53.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e637 (50.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u0026ndash;2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3,038 (28.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e367 (29.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3\u0026ndash;4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e971 (9.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e129 (10.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5 or higher\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e915 (8.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e124 (9.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eColonoscopy Ordered By\u003c/strong\u003e\u003csup\u003ef\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAttending\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e8,542 (80.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e878 (69.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNurse Practitioner\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e448 (4.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e58 (4.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eResident\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1,586 (15.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e321 (25.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003ePortal Use\u003c/strong\u003e\u003csup\u003eg\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e7,084 (67.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1,091 (86.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3,492 (33.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e166 (13.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eColonoscopy Ordered During COVID\u003c/strong\u003e\u003csup\u003eh\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e7,322 (69.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e878 (69.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3,254 (30.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e379 (30.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eIndex Visit Modality\u003c/strong\u003e\u003csup\u003ei\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIn person\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e8,158 (77.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1,010 (80.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTelephone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e705 (6.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e100 (8.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eVideo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e293 (2.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12 (1.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMissing\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1,420 (13.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e135 (10.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eRectal Bleeding\u003c/strong\u003e\u003csup\u003ej\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e574 (5.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e88 (7.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e9,991 (94.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1,167 (92.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMissing\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e11 (0.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (0.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003ePractice Site\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCommunity Health Center\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1,269 (12.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e367 (29.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHospital-based practice\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e9,307 (88.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e890 (70.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eColonoscopy Completion in 1 Year\u003c/strong\u003e\u003csup\u003el\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4,628 (43.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e624 (49.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e5,948 (56.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e633 (50.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\"\u003ea. SD denotes standard deviation.\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\"\u003eb. Missing refers to the absence of data in the electronic health record.\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\"\u003ec. Patients without education data were coded as \u0026ldquo;missing\u0026quot; Those with a high school diploma or less were categorized as \u0026quot;high school or below\u0026quot;, and all others as \u0026quot;greater than high school.\u0026rdquo;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\"\u003ed. Depression was defined using ICD-10 codes (F32.xx-F33.xx).\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\"\u003ee. Charlson Co-morbidity Index (\u003cspan class=\"CitationRef\"\u003e12\u003c/span\u003e) was calculated from billing diagnoses for all encounters within 2 years of the index referral date. Patients were classified into 3 categories based on their score: 0, 1\u0026ndash;2,\u0026gt;=3.\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\"\u003ef. Colonoscopy orders were placed by attending physicians, nurse practitioners, and residents.\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\"\u003eg. Patient portal use was defined as registration on the patient site and viewing at least one note.\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\"\u003eh. We defined colonoscopy ordering during COVID as colonoscopy ordered between March 1st, 2020 and December 31st, 2021.\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\"\u003ei. Visit modality was separated into in-person, video, or telephone.\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\"\u003ej. Rectal bleeding was defined using ICD-10 codes (K62.5, K92.2, K51.911).\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\"\u003ek. \u0026lsquo;Medicare\u0026rsquo; includes all Medicare products (Advantage and traditional). \u0026lsquo;Medicaid\u0026rsquo; includes all Masshealth products including Masshealth ACO, Masshealth Limited, and Masshealth Standard. \u0026lsquo;Commercial\u0026rsquo; includes all HMO and PPO insurance plans excluding Medicare Advantage plans and subsidized \u0026ldquo;Connector\u0026rdquo; plans (i.e. \u0026lsquo;Subsidized\u0026rsquo;). \u0026lsquo;Medicare/Medicaid\u0026rsquo; includes those with dual coverage. \u0026lsquo;Other\u0026rsquo; includes all other plans not falling into above categories.\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\"\u003el. Colonoscopy completion in 1 year was defined as completion within 365 days of ordering\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003cdiv align=\"left\" class=\"colspec\"\u003e\u003cbr\u003e\u003c/div\u003e\n \u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eAdjusted Hazard Ratios (HRs) for Colonoscopy Completion\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eFactor\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMain Analysis HR (95% CI)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eSensitivity Analysis HR (95% CI)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.00 [0.96, 1.05]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.00 [0.99, 1.02]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eSex\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFemale (Reference)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.09 [1.03, 1.14]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.00 [0.85, 1.17]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eHispanic\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo (Reference)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.01 [0.91, 1.12]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.94 [0.74, 1.20]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMissing\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.91 [0.80, 1.03]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.53 [0.32, 0.87]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eEducation\u003c/strong\u003e\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHigh school or less (Reference)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGreater than high school\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.07 [1.01, 1.14]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.18 [0.97, 1.44]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMissing\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.01 [0.93, 1.10]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.97 [0.75, 1.24]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eDepression\u003c/strong\u003e\u003csup\u003ed\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo (Reference)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.95 [0.89, 1.01]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.92 [0.76, 1.10]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eCharlson Comorbidity Score\u003c/strong\u003e\u003csup\u003ee\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 (Reference)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u0026ndash;2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.00 [0.94, 1.06]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.95 [0.80, 1.13]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3\u0026ndash;4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.04 [0.95, 1.13]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.88 [0.67, 1.15]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5 or higher\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.93 [0.84, 1.02]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.77 [0.58, 1.03]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eColonoscopy Ordered By\u003c/strong\u003e\u003csup\u003ef\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAttending (Reference)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNurse Practitioner\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.77 [0.68, 0.88]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.92 [0.63, 1.35]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eResident\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.92 [0.85, 0.99]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.08 [0.89, 1.31]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003ePatient Portal Use\u003c/strong\u003e\u003csup\u003eg\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo (Reference)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.19 [1.13, 1.26]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.03 [0.81, 1.32]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eColonoscopy Ordered During COVID\u003c/strong\u003e\u003csup\u003e\u003cstrong\u003eh\u003c/strong\u003e\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo (Reference)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.93 [0.87, 0.99]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.08 [0.90, 1.31]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eIndex Visit Modality\u003c/strong\u003e\u003csup\u003ei\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIn person (Reference)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTelephone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.56 [0.49, 0.64]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.52 [0.35, 0.75]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eVideo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.76 [0.63, 0.90]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.66 [0.27, 1.63]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMissing\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.15 [1.07, 1.24]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.10 [0.85, 1.42]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eRectal Bleeding\u003c/strong\u003e\u003csup\u003ej\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo (Reference)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.88 [1.69, 2.08]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.65 [1.24, 2.20]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMissing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.46 [0.69, 3.07]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.19 [1.03, 17.11]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eRace\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWhite (Reference)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAsian\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.02 [0.90, 1.14]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.06 [0.76, 1.48]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBlack\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.08 [1.02, 1.16]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.98 [0.80, 1.20]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.03 [0.91, 1.16]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.06 [0.81, 1.40]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMissing\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.91 [0.78, 1.07]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.95 [0.61, 1.50]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eInsurance\u003c/strong\u003e\u003csup\u003ek\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCommercial (Reference)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMedicaid\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.82 [0.75, 0.89]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMedicare\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.01 [0.94, 1.08]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMedicare and Medicaid\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.86 [0.74, 0.99]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.63 [0.50, 0.79]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSubsidized\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.80 [0.69, 0.91]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003ePractice Site\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHospital-based practice (Reference)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCommunity Health Center\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.13 [1.03, 1.24]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.32 [1.07, 1.62]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eEnglish Language\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes (Reference)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.23 [1.12, 1.34]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.16 [0.95, 1.41]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMissing\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.77 [0.46, 1.27]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.03 [0.37, 2.85]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\"\u003ea. SD denotes standard deviation.\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\"\u003eb. Missing refers to the absence of data in the electronic health record.\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\"\u003ec. Patients without education data were coded as \u0026ldquo;missing\u0026quot; Those with a high school diploma or less were categorized as \u0026quot;high school or below\u0026quot;, and all others as \u0026quot;greater than high school.\u0026rdquo;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\"\u003ed. Depression was defined using ICD-10 codes (F32.xx-F33.xx).\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\"\u003ee. Charlson Co-morbidity Index (\u003cspan class=\"CitationRef\"\u003e12\u003c/span\u003e) was calculated from billing diagnoses for all encounters within 2 years of the index referral date. Patients were classified into 3 categories based on their score: 0, 1\u0026ndash;2, \u0026gt;=3.\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\"\u003ef. Colonoscopy orders were placed by attending physicians, nurse practitioners, and residents.\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\"\u003eg. Patient portal use was defined as registration on the patient site and viewing at least one note.\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\"\u003eh. We defined colonoscopy ordering during COVID as colonoscopy ordered between March 1st, 2020 and December 31st, 2021.\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\"\u003ei. Visit modality was separated into in-person, video, or telephone.\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\"\u003ej. Rectal bleeding was defined using ICD-10 codes (K62.5, K92.2, K51.911).\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\"\u003ek. \u0026lsquo;Medicare\u0026rsquo; includes all Medicare products (Advantage and traditional). \u0026lsquo;Medicaid\u0026rsquo; includes all Masshealth products including Masshealth ACO, Masshealth Limited, and Masshealth Standard. \u0026lsquo;Commercial\u0026rsquo; includes all HMO and PPO insurance plans excluding Medicare Advantage plans and subsidized \u0026ldquo;Connector\u0026rdquo; plans (i.e. \u0026lsquo;Subsidized\u0026rsquo;). \u0026lsquo;Medicare/Medicaid\u0026rsquo; includes those with dual coverage. \u0026lsquo;Other\u0026rsquo; includes all other plans not falling into above categories.\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\"\u003el. Colonoscopy completion in 1 year was defined as completion within 365 days of ordering.\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eIn the primary analysis using a Cox proportional hazards model, earlier completion of colonoscopy was associated with several factors - higher education, non-English language preference, Black race, male sex, rectal bleeding diagnosis, electronic patient portal use, and care at the community health center practice. Compared to female patients, male patients were more likely to complete colonoscopy earlier (HR 1.09, 95% CI [1.03, 1.14]). Non-English-speaking patients were also more likely to complete colonoscopy earlier than English speakers (HR 1.23, 95% CI [1.12, 1.34]). Black patients were more likely than White patients to complete colonoscopy earlier (HR 1.08, 95% CI [1.02, 1.16]). Patients with rectal bleeding and those using the patient portal had a substantially higher likelihood of earlier completion (HR 1.88, 95% CI [1.69, 2.08] and HR 1.19, 95% CI [1.13, 1.26], respectively). Similarly, patients receiving care at the community health center practice were significantly more likely to complete colonoscopy earlier than those seen in the hospital-based practice (HR 1.13, 95% CI [1.03, 1.24]), as shown in Fig. \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e, which displays unadjusted cumulative probability of completing a colonoscopy test during the period of follow-up by practice setting (p\u0026thinsp;\u0026lt;\u0026thinsp;0.01). [Figure \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e]\u003c/p\u003e\n\u003cp\u003eBy contrast, orders placed by nurse practitioners (HR 0.77, 95% CI [0.68, 0.88]) or residents (HR 0.92, 95% CI [0.85, 0.99]) were associated with later completion compared to those placed by attending physicians. Compared to patients with commercial insurance, later test completion was observed for those with Medicaid (HR 0.82, 95% CI [0.75, 0.89]), dual coverage (Medicaid and Medicare) (HR 0.86, 95% CI [0.74, 0.99]), or subsidized commercial insurance (HR 0.80, 95% CI [0.69, 0.91]). Additionally, colonoscopies ordered during the COVID pandemic were more likely to be completed later than those ordered before the pandemic (HR 0.93, 95% CI [0.87, 0.99]).\u003c/p\u003e\n\u003cp\u003eThe sensitivity analysis results (i.e. Medicaid ACO patients only) are consistent in directionality with those of the primary analysis, with the exception that Black race is no longer significant for earlier colonoscopy completion.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eFrom 2018 to 2021 in this US-based system, 56% of 10,576 colonoscopies ordered in primary care were completed within one year, indicating a need for primary care-based interventions to improve timely colonoscopy completion as has been discussed elsewhere (9, 11). For patients in our cohort who completed their colonoscopy during the period of follow up, several unique factors that modify the rate of completion can inform future interventions and research. For instance, earlier colonoscopy completion among CHC patients -adjusted for race, language, ethnicity and education- compared to patients seen at a hospital-based practice is a novel finding. We hypothesize that this finding relates to organizational cultural competency at the CHC that historically has provided enhanced support, reminders, and instruction around colonoscopy scheduling and completion compared to the hospital-based primary care practice. Patient navigation was demonstrated to be an effective strategy to increase colonoscopy test completion in select high risk populations (13). Understanding and describing how CHCs intentionally support and help patients navigate the process of getting a diagnostic test can delineate best practices to guide other primary care sites. The slower completion of colonoscopy tests when ordered at phone and video appointments or by NPs or resident MDs –as our research group has shown elsewhere for a range of test orders (10)- should prompt practices to enhance test coordination efforts –assisted scheduling, reminder calls- after virtual visits or when ordered by a NP or resident. We also observed that patients with subsidized –high deductible- commercial insurance completed tests much later than other commercial insurance types. This finding is in keeping with studies that have shown barriers to CRC screening among uninsured or underinsured patients (14), indicating a need for research to explore nuances in the relationship between health disparities and insurance status.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOur focus on colonoscopy -screening and diagnostic- shapes and limits the implications of our findings. Although our analysis adjusted for rectal bleeding diagnosis to account for diagnostic colonoscopies ordered within our sample, we cannot otherwise reliably distinguish diagnostic from screening tests. Relying on EHR documentation of test completion (vs claims) in our sample could have missed tests completed outside the hospital system. We addressed this by examining the ACO Medicaid population separately, which showed consistent directionality with point estimates in the primary analysis, except for Black patients. The finding that Black patients had earlier test completion in the full analysis but not in the sensitivity analysis may reflect unmeasured confounders when controlling for insurance type or may be a function of the smaller sample size.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOther types of colon cancer tests were not included in our dataset. Hence, the observation that non-English speakers are more likely to have earlier colonoscopy completion in our cohort may reflect factors influencing the likelihood of ordering a colonoscopy, as described elsewhere, including patient preference, provider bias, health literacy, availability of stool-based tests, and social support (15). More study is needed to understand the interconnected processes of colon cancer test selection and test completion, particularly among LEP populations. More studies are also needed to examine whether the positive relationship between patient portal use and earlier colonoscopy completion –as observed for other diagnostic testing loops (16)- is causal, or a proxy for patient activation. We are encouraged that a diagnosis of rectal bleeding is associated with earlier test completion, suggesting underlying system resiliency factors that can be instructive for improving colonoscopy test completion more generally.\u003c/p\u003e\n\u003cp\u003eWe recognize that timely colonoscopy completion is one of several mechanisms that account for population differences in colorectal cancer health outcomes. Earlier test completion for some may not translate into earlier treatment or greater survival, due to underlying risks that are independent of screening or prompt diagnosis (5). More research is needed to fill in the map of intervenable factors along the screening, diagnosis and treatment journey that optimize colorectal cancer outcomes.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThe low rate (56%) of colonoscopy order completion within one year among primary care patients in a US-based hospital system underscores the need to identify, address, and harness factors that modify the timeliness of completion. Location of care (CHC practice), using an electronic patient portal, higher education, speaking a non-English language, and having a diagnosis of rectal bleeding were factors associated with earlier colonoscopy completion, whereas colonoscopy orders originating from a telehealth visit or ordered by a NP or resident and patients with depression, Medicaid, or subsidized commercial insurance had later completion. \u0026nbsp;Some of these factors lend themselves to systems interventions, and some stimulate novel hypotheses for research efforts to improve timely colonoscopy completion.\u0026nbsp;\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eACO\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eAccountable Care Organization\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCHC\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eCommunity Health Center\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCRC\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eColorectal cancer\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eEHR\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eElectronic health record\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eHR\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eHazards ratio\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eNP\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eNurse practitioner\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eUS\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eUnited States\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003eHuman Ethics and Consent to Participate declarations: Per regulation 45 CFR 46.104(d) (2)(2), consent to participate was not required for this study of retrospective anonymized data where no human subjects were included. Our study adheres to the Declaration of Helsinki with regard to research conducted on human data. The data used for this research was approved by the BIDMC Committee on Clinical Investigation (2020P000502).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eConsent for publication: Anonymized data was used in this study. Therefore, participant consent to publish was not necessary.\u003c/p\u003e\n\u003cp\u003eData availability: Datasets used for the analysis are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003eCompeting interests: The authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003eFunding: Research was supported by AHRQ patient safety grant, R18HS027282.\u003c/p\u003e\n\u003cp\u003eAuthors’ contributions: TS, LF, RP, CD, and CZ jointly developed the research aim and methodology. CZ performed the Cox regression analyses and prepared Figure 1. TS and AZ conducted the historical data analysis. TS drafted the manuscript. LF, AZ, RP, CD, and CZ provided key edits and suggestions.\u003c/p\u003e\n\u003cp\u003eAcknowledgements: We wish to acknowledge Umber Shafiq and Naing Aung who aided with dataset refinement.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eHollis RH, Chu DI. Healthcare Disparities and Colorectal Cancer. Surg Oncol Clin N Am. 2022 Apr;31(2):157-169. Epub 2022 Mar 8.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eMcLeod MR, Galoosian A, May FP. Racial and Ethnic Disparities in Colorectal Cancer Screening and Outcomes. Hematol Oncol Clin North Am. 2022 Jun;36(3):415-428. Epub 2022 Apr 30.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eLiss DT, Baker DW. Understanding current racial/ethnic disparities in colorectal cancer screening in the United States: the contribution of socioeconomic status and access to care. Am J Prev Med. 2014 Mar;46(3):228-36.\u003c/li\u003e\n \u003cli\u003eThompson T, McQueen A, Croston M, Luke A, Caito N, Quinn K, Funaro J, Kreuter MW. Social Needs and Health-Related Outcomes Among Medicaid Beneficiaries. Health Educ Behav. 2019 Jun;46(3):436-444. Epub 2019 Jan 17.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eCarethers JM, Doubeni CA. Causes of Socioeconomic Disparities in Colorectal Cancer and Intervention Framework and Strategies. Gastroenterology. 2020 Jan;158(2):354-367. Epub 2019 Nov 1.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eJones LA, Ferrans CE, Polite BN, Brewer KC, Maker AV, Pauls HA, Rauscher GH. Examining racial disparities in colon cancer clinical delay in the Colon Cancer Patterns of Care in Chicago study. Ann Epidemiol. 2017 Nov;27(11):731-738.e1 Epub 2017 Oct 13.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eUngvari Z, Fekete M, Fekete JT, Lehoczki A, Buda A, Munk\u0026aacute;csy G, Varga P, Ungvari A, Győrffy B. Treatment delay significantly increases mortality in colorectal cancer: a meta-analysis. Geroscience. 2025 Apr 8;47(3):5337\u0026ndash;53. Epub ahead of print.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eLansdorp-Vogelaar I, Kuntz KM, Knudsen AB, van Ballegooijen M, Zauber AG, Jemal A. Contribution of screening and survival differences to racial disparities in colorectal cancer rates. Cancer Epidemiol Biomarkers Prev. 2012 May;21(5):728-36. Epub 2012 Apr 18.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eThamarasseril S, Bhuket T, Chan C, Liu B, Wong RJ. The Need for an Integrated Patient Navigation Pathway to Improve Access to Colonoscopy After Positive Fecal Immunochemical Testing: A Safety-Net Hospital Experience. J Community Health. 2017 Jun;42(3):551-557.\u003c/li\u003e\n \u003cli\u003eZhong A, Amat MJ, Anderson TS, Shafiq U, Sternberg SB, Salant T, Fernandez L, Schiff GD, Aronson MD, Benneyan JC, Singer SJ, Phillips RS. Completion of Recommended Tests and Referrals in Telehealth vs In-Person Visits. JAMA Netw Open. 2023 Nov 1;6(11):e2343417.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eCampbell KA, Sternberg SB, Benneyan J, Flier SN, Amat M, Salant T, Nambara K, Fernandez L, Feuerstein J, Shafiq U, Phillips RS, Aronson MD, Schiff GD. Completion Rates and Timeliness of Diagnostic Colonoscopies for Rectal Bleeding in Primary Care. J Gen Intern Med. 2024 May;39(6):985-991. Epub 2023 Nov 8.\u003c/li\u003e\n \u003cli\u003eCharlson ME, Charlson RE, Peterson JC, Marinopoulos SS, Briggs WM, Hollenberg JP. The Charlson comorbidity index is adapted to predict costs of chronic disease in primary care patients. J Clin Epidemiol. 2008 Dec;61(12):1234-1240.\u003c/li\u003e\n \u003cli\u003eWhitley EM, Raich PC, Dudley DJ, Freund KM, Paskett ED, Patierno SR, Simon M, Warren-Mears V, Snyder FR; Patient Navigation Research Program Investigators. Relation of comorbidities and patient navigation with the time to diagnostic resolution after abnormal cancer screening. Cancer. 2017 Jan 1;123(2):312-318. Epub 2016 Sep 20. \u0026nbsp;\u003c/li\u003e\n \u003cli\u003eZhao G, Okoro CA, Li J, Town M. Health Insurance Status and Clinical Cancer Screenings Among U.S. Adults. Am J Prev Med. 2018 Jan;54(1):e11-e19.\u003c/li\u003e\n \u003cli\u003eZhu X, Parks PD, Weiser E, Fischer K, Griffin JM, Limburg PJ, Finney Rutten LJ. National Survey of Patient Factors Associated with Colorectal Cancer Screening Preferences. Cancer Prev Res (Phila). 2021 May;14(5):603-614. \u0026nbsp;Epub 2021 Apr 22.\u003c/li\u003e\n \u003cli\u003eBell SK, Amat MJ, Anderson TS, Aronson MD, Benneyan JC, Fernandez L, Ricci DA, Salant T, Schiff GD, Shafiq U, Singer SJ, Sternberg SB, Zhang C, Phillips RS. Do patients who read visit notes on the patient portal have a higher rate of \u0026quot;loop closure\u0026quot; on diagnostic tests and referrals in primary care? A retrospective cohort study. J Am Med Inform Assoc. 2024 Feb 16;31(3):622-630.\u003cstrong\u003e\u003cbr\u003e\u0026nbsp;\u003c/strong\u003e\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-gastroenterology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmge","sideBox":"Learn more about [BMC Gastroenterology](http://bmcgastroenterol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bmge/default.aspx","title":"BMC Gastroenterology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Colonoscopy, diagnostic delay, primary care","lastPublishedDoi":"10.21203/rs.3.rs-7861275/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7861275/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eTimely colonoscopy completion in primary care can prevent diagnostic delays in colorectal cancer. Factors that influence why patients experience timely or delayed colonoscopy completion are unclear. We sought to identify potentially intervenable factors associated with earlier (or later) colonoscopy test completion in primary care.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eAll colonoscopy orders placed by primary care clinicians in two clinics within a single hospital system between January 1 2018 and December 31 2021 were examined for time to completion using Cox Proportional Hazards Model, where the hazards of completion were adjusted for variables potentially associated with the outcome, including sociodemographic, individual health-related, and care delivery factors.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eAmong 10,576 colonoscopy tests ordered, 56% were completed within one year. After multivariable adjustment, earlier colonoscopy completion was associated with receiving care at a community health center, preferred spoken language other than English, male sex, Black race, any college education, a diagnosis of rectal bleeding, and documented use of an electronic patient portal. Completion occurred later among patients with Medicaid insurance, subsidized commercial insurance, or depression, and among patients whose tests were ordered by a nurse practitioner or a resident, or during a telehealth appointment. Results were similar for a sensitivity analysis restricted to those patients within a Medicaid ACO, except for the finding that Black race was no longer associated with test completion.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eBased on our findings, certain factors associated with \u0026ndash;early or delayed- colonoscopy test completion lend themselves to possible interventions. Targeted care navigation (e.g. reminder calls, assisted scheduling, transportation assistance) may be needed for patients whose colonoscopy tests are ordered at telehealth appointments or by NPs or residents, or who have certain insurance types (e.g. Medicaid and high-deductible insurance). Harnessing strategies used at community health centers to improve culturally competent test scheduling may also be a promising area of future work to help patients book and attend colon cancer test appointments. More study is needed to understand the observed relationship between electronic portal use and test completion and why some patient characteristics such as non-English preference are associated with earlier completion of ordered tests in our study.\u003c/p\u003e","manuscriptTitle":"The role of health, sociodemographic, and care delivery factors in timely completion of colonoscopy in a US-based primary care population: a retrospective analysis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-03 09:39:47","doi":"10.21203/rs.3.rs-7861275/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-11-24T05:00:01+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-21T22:01:39+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-13T03:03:06+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"11044524694649124888387790160471742384","date":"2025-11-06T16:52:54+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"200487406831185270259486796272439117427","date":"2025-11-05T16:18:05+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-31T19:23:07+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-27T00:24:10+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"176694026227528782574119120749694766463","date":"2025-10-24T18:38:42+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"279374749437171339447367387220989127630","date":"2025-10-22T18:28:59+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-10-22T18:19:00+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-10-21T11:00:23+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-10-20T06:34:36+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-10-17T18:35:05+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Gastroenterology","date":"2025-10-17T18:32:33+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-gastroenterology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmge","sideBox":"Learn more about [BMC Gastroenterology](http://bmcgastroenterol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bmge/default.aspx","title":"BMC Gastroenterology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"c1137a82-4ed2-449c-b589-7116e31059a1","owner":[],"postedDate":"November 3rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-01-19T16:50:06+00:00","versionOfRecord":{"articleIdentity":"rs-7861275","link":"https://doi.org/10.1186/s12876-026-04612-z","journal":{"identity":"bmc-gastroenterology","isVorOnly":false,"title":"BMC Gastroenterology"},"publishedOn":"2026-01-15 16:31:09","publishedOnDateReadable":"January 15th, 2026"},"versionCreatedAt":"2025-11-03 09:39:47","video":"","vorDoi":"10.1186/s12876-026-04612-z","vorDoiUrl":"https://doi.org/10.1186/s12876-026-04612-z","workflowStages":[]},"version":"v1","identity":"rs-7861275","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7861275","identity":"rs-7861275","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}