Background The effectiveness of colorectal cancer (CRC) screening is limited by underuse, particularly among underserved populations. Among a racially diverse and socioeconomically disadvantaged cohort of patients, we compared effectiveness of FIT outreach and colonoscopy outreach to increase screening participation rates, compared to usual visit-based care. Methods Patients, aged 50–64 years who were not up-to-date with CRC screening, but used primary care services in a large safety-net health system were randomly assigned to mailed FIT outreach (n=2400), mailed colonoscopy outreach (n=2400), or usual care with opportunistic visit-based screening (n=1199). Patients who did not respond to outreach invitations within 2 weeks received follow-up telephone reminders. The primary outcome was CRC screening completion within 12 months after randomization. Results Baseline patient characteristics across groups were similar. Using intention-to-screen analysis, screening participation rates were higher for FIT outreach (58.8%) and colonoscopy outreach (42.4%) than usual care (29.6%) (p< 0.001 for both). Screening participation with FIT outreach was higher than colonoscopy outreach (p< 0.001). Among responders, FIT outreach had a higher proportion who responded prior to reminders (59.0% vs. 29.7%, p< 0.001). Nearly half of colonoscopy outreach patients crossed over to complete FIT via usual care, whereas <5% of FIT outreach patients underwent usual care colonoscopy. Conclusions Mailed outreach invitations can significantly increase CRC screening rates among underserved populations. FIT-based outreach was more effective than colonoscopy-based outreach to increase one-time screening participation. Studies with longer follow-up are needed to compare effectiveness of outreach strategies for promoting completion of the entire screening process.

IMPORTANCE Mailed fecal immunochemical test (FIT) outreach is more effective than colonoscopy outreach for increasing 1-time colorectal cancer (CRC) screening, but long-term effectiveness may need repeat testing and timely follow-up for abnormal results.OBJECTIVE Compare the effectiveness of FIT outreach and colonoscopy outreach to increase completion of the CRC screening process (screening initiation and follow-up) within 3 years. DESIGN, SETTING, AND PARTICIPANTS Pragmatic randomized clinical trial from March 2013 to July 2016 among 5999 participants aged 50 to 64 years who were receiving primary care in Parkland Health and Hospital System and were not up to date with CRC screenings.INTERVENTIONS Random assignment to mailed FIT outreach (n = 2400), mailed colonoscopy outreach (n = 2400), or usual care with clinic-based screening (n = 1199). Outreach included processes to promote repeat annual testing for individuals in the FIT outreach group with normal results and completion of diagnostic and screening colonoscopy for those with an abnormal FIT result or assigned to colonoscopy outreach. MAIN OUTCOMES AND MEASURESPrimary outcome was screening process completion, defined as adherence to colonoscopy completion, annual testing for a normal FIT result, diagnostic colonoscopy for an abnormal FIT result, or treatment evaluation if CRC was detected. Secondary outcomes included detection of any adenoma or advanced neoplasia (including CRC) and screening-related harms (including bleeding or perforation).RESULTS All5999participants(medianage,56years;women,61.9%)wereincludedintheintentionto-screen analyses. Screening process completion was 38.4% in the colonoscopy outreach group, 28.0% in the FIT outreach group, and 10.7% in the usual care group. Compared with the usual care group, between-group differences for completion were higher for both outreach groups, and highest in the colonoscopy outreach group. Compared with usual care, the between-group differences in adenoma and advanced neoplasia detection rates were higher for both outreach groups, and highest in the colonoscopy outreach group. There were no screening-related harms in any groups. Between-Group Differences, % (95% CI) Colonoscopy Outreach vs Usual Care P Value FIT Outreach vs Usual Care P Value Colonoscopy Outreach vs FIT Outreach P Value Screening process completion 27.7 (25.1 to 30.4) <.001 17.3 (14.8 to 19.8) <.001 10.4 (7.8 to 13.1) <.001 Detection rate for adenoma 10.3 (9.5 to 12.1) <.001 1.3 (−0.1 to 2.8) .08 9.0 (7.3 to 10.7) <.001 Detection rate for advanced neoplasia 3.1 (2.0 to 4.1) <.001 0.7 (−0.2 to 1.6) .13 2.4 (1.3 to 3.3) <.001CONCLUSIONS AND RELEVANCE Among persons aged 50 to 64 years receiving primary care at a safety-net institution, mailed outreach invitations offering FIT or colonoscopy compared with usual care increased the proportion completing CRC screening process within 3 years. The rate of screening process completion was higher with colonoscopy than FIT outreach.

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Background: Surveillance colonoscopy is required in patients with polyps due to an elevated colorectal cancer (CRC) risk; however, studies suggest substantial overuse and underuse of surveillance colonoscopy. The goal of this study was to characterize guideline adherence of surveillance recommendations after implementation of an electronic medical record (EMR)-based Colonoscopy Pathology Reporting and Clinical Decision Support System (CoRS). Methods: We performed a retrospective cohort study of patients who underwent colonoscopy with polypectomy at a safety-net healthcare system before (n=1,822) and after (n=1,320) implementation of CoRS in December 2013. Recommendations were classified as guideline-adherent or nonadherent according to the US Multi-Society Task Force on CRC. We defined surveillance recommendations shorter and longer than guideline recommendations as potential overuse and underuse, respectively. We used multivariable generalized linear mixed models to identify correlates of guideline-adherent recommendations. Results: The proportion of guideline-adherent surveillance recommendations was significantly higher post-CoRS than pre-CoRS (84.6% vs 77.4%; P<.001), with fewer recommendations for potential overuse and underuse. In the post-CoRS period, CoRS was used for 89.8% of cases and, compared with cases for which it was not used, was associated with a higher proportion of guideline-adherent recommendations (87.0% vs 63.4%; RR, 1.34; 95% CI, 1.23-1.42). In multivariable analysis, surveillance recommendations were also more likely to be guideline-adherent in patients with adenomas but less likely among those with fair bowel preparation and those with family history of CRC. Of 203 nonadherent recommendations, 70.4% were considered potential overuse, 20.2% potential underuse, and 9.4% were not provided surveillance recommendations. Conclusions: An EMR-based CoRS was widely used and significantly improved guideline adherence of surveillance recommendations.Colorectal cancer (CRC) screening can reduce CRC incidence and mortality. 1 Although CRC screening can be performed using stool-based methods or colonosco-py, many US providers prefer colonoscopy because it is both diagnostic and therapeutic, permitting simultaneous removal of precancerous lesions. 2,3

CoRS is well-accepted by clinicians and provides guideline-based recommendations and results communications to patients and providers.