Areas for Improvement

While national studies have shown significant disparities in CRC screening based on race and ethnicity, “the amazing thing about the VA is that these disparities have closed. Blacks have the highest rates of CRC and highest mortality rates as well. In the VA, they have the highest screening rate and Hispanics have higher or similar rates to whites,” May observed. Asians also had higher screening rates than whites. Screening rates rose with veteran age and number of comorbidities.

The study did identify other disparities, however. For veterans with serious mental illness, substance abuse issues, low income status or American Indian/Alaskan Native ethnicity, the odds of being screened were 24% to 35% lower than white veterans. Veterans with serious mental illness had the lowest rates, but, even among them, more than 75% were current on their screening.

Screening among American Indian/Native Alaskan veterans could be increased by focusing on a few VA facilities that take care of this population, May said. “We don’t need to change hundreds of VA sites to impact Native Americans, but, to increase screening among veterans with serious mental health conditions, we may need to involve all our sites.”

While patients with mental health conditions have frequent points of contact with the VA, those often occur in mental health clinics or the emergency department, where other issues take priority. Even in primary care settings, patients with serious mental illness or substance use disorder may not receive recommendations for screening, May noted.

“For patients with multiple medications, acute mental health issues and other medical issues, there just isn’t the time in primary care to follow-up on screening,” May explained. “We may need to go an extra step to ensure they have follow-up and options that work, if they are homeless or face other barriers. Perhaps we could use patient navigators or care managers to provide step-by-step care and education.”

May FP, Yano EM, Provenzale D, Steers WN, Washington DL. Race, Poverty, and Mental Health Drive Colorectal Cancer Screening Disparities in the Veterans Health Administration. Med Care. 2019 Oct;57(10):773-780