Effectiveness of a Mailed Colorectal Cancer Screening Outreach Program in Community Health Clinics

Abstract

IMPORTANCE Approximately 24 million US individuals receive care at federally qualified health centers, which historically have low rates of colorectal cancer screening. The US Preventive Services Task Force recommends routine colorectal cancer screening for individuals aged 50 to 75 years. OBJECTIVE To determine the effectiveness of an electronic health record (EHR)-embedded mailed fecal immunochemical test (FIT) outreach program implemented in health centers as part of standard care. DESIGN, SETTING, AND PARTICIPANTS This cluster randomized pragmatic clinical trial was conducted in 26 federally qualified health center clinics, representing 8 health centers in Oregon and California, randomized to intervention (n = 13) or usual care (n = 13). All participants were overdue for colorectal cancer screening during the accrual interval (February 4, 2014 to February 3, 2015). INTERVENTIONS Electronic health record-embedded tools to identify eligible adults and to facilitate implementation of a stepwise mailed intervention involving (1) an introductory letter, (2) a mailed FIT, and (3) a reminder letter; training, collaborative learning, and facilitation through a practice improvement process. MAIN OUTCOMES AND MEASURES Effectiveness was measured as clinic-level proportions of adults who completed a FIT, and secondarily, any colorectal cancer screening within 12 months of accrual or by August 3, 2015. Implementation was measured as clinic-level proportions of adults who were mailed an introductory letter and ordered a FIT. RESULTS Twenty-six clinics with 41 193 adults (mean [SD] age, 58.5 [6.3] years; 22 994 women) were randomized to receive the direct mail colorectal screening intervention (13 clinics; 21 134 patients) or usual care (13 clinics; 20 059 patients). Compared with usual care clinics, intervention clinics had significantly higher adjusted clinic-level proportion of participants who completed a FIT (13.9% vs 10.4%; difference, 3.4 percentage points; 95% CI, 0.1%-6.8%) and any colorectal cancer screening (18.3% vs 14.5%; difference, 3.8 percentage points; 95% CI, 0.6%-7.0%). We observed large variation across health centers in effectiveness (FIT completion differences range, −7.4 percentage points to 17.6 percentage points) and implementation (proportion who were mailed a FIT range, 6.5% to 68.2%). The number needed to mail to achieve a completed FIT was 4.8 overall, and 4.0 in clinics that mailed a FIT reminder. CONCLUSIONS AND RELEVANCE An EHR-embedded mailed FIT outreach intervention significantly improved rates of FIT completion and rates of any colorectal cancer screening. Higher rates of colorectal cancer screening occurred in clinics that successfully implemented the mailed outreach program. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT01742065

Direct‐to‐member mailed colorectal cancer screening outreach for Medicaid and Medicare enrollees: Implementation and effectiveness outcomes from the BeneFIT study

“…The current study data concerning follow‐up colonoscopy completion rates (33% to 36%) indicated room for improvement in both health plans. Low participation in follow‐up colonoscopy is a recognized limitation of FIT‐based programs, and the rates observed herein were even lower than the 52% to 53% found in previous research involving health centers serving the Medicaid population . In Health Plan Washington, this finding may have been attributable to low reach (60.0%) of the care coordinator telephone calls and/or the care coordinators' inability to directly inform patients of their test results.…”

First-year implementation of mailed FIT colorectal cancer screening programs in two Medicaid/Medicare health insurance plans: qualitative learnings from health plan quality improvement staff and leaders

“…This research demonstrates the feasibility of implementing mailed FIT programs tailored to health plans based on their resources and preferences, as well as the substantial successes and addressable challenges that health plans experience as they work to lower rates of CRC and cancer death among their members. The two health plans participating in this study successfully adapted the components of prior clinic-and health system-based mailed FIT programs [4,6,8] to their own culture and resources, and found that their programs were a good fit with their organizational mission and goals. The availability of quality management resources allowed the health plans to overcome the most commonly described challenges reported for clinic-and health system-based mailed FIT programs-the time needed to set up and administer the program.…”

“…Mailing fecal immunochemical test (FIT) kits to patients who are due for CRC screening is an evidence-based strategy for increasing CRC screening that has been tested by clinics and health care systems [4][5][6][7][8][9] (e.g., CRC screening rates have increased from 26.3 to 50.8% in primary care clinics in a large nonprofit health care delivery system [8], from 17.8 to 56.5% in rural family physician offices [9]). Health insurance plans are now beginning to implement mailed FIT screening programs [10].…”

Concept Analysis of Community Health Outreach: a systematic review

“…These outreach events, which formed partnerships with community healthcare systems to care for underserved groups, were implemented from 2010 to 2012, and about 81% of attendees received colorectal cancer screenings [15]. Meanwhile, an outreach program providing mailing service for fecal occult blood test kits has also been reported to be an effective strategy for increasing of colorectal cancer screening uptake [16,17]. The Helping Her Live project, which seeks to improve breast screenings and follow-ups for abnormal breast screening findings, has been implemented among minority women experiencing racial disparities in Chicago since 2008.…”