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Reasons for never and intermittent completion of colorectal cancer screening after receiving multiple rounds of mailed fecal tests.

ABSTRACT: BACKGROUND:Long-term adherence to colorectal cancer (CRC) screening is particularly important for fecal testing. Some U.S. studies report that only 25% of individuals repeat fecal testing annually. The purpose of this qualitative study was to identify barriers and facilitators reported by patients with suboptimal screening adherence to refine interventions for starting ongoing adherence to CRC screening. We also explored whether participants, particularly never screeners, would be willing to do a CRC screening blood test. METHODS:Forty-one patients who previously enrolled in the Systems of Support to Increase CRC Screening (SOS) trial were interviewed 4-5 years later. Participants were purposively selected to include men and women with diverse race/ethnicities who had either been inconsistent screeners or had never screened during the first three years of SOS despite receiving at least two rounds of mailed fecal tests. Two interviewers conducted 30-min telephone interviews using a semi-structured interview guide. An iterative thematic analysis approach was used. RESULTS:Themes related to screening barriers were more pervasive among never screeners including: (1) Avoidance (inattention, procrastination) (2) Concerns about handling stool; (3) Health concerns; (4) Fear of a cancer diagnosis or positive test results. Themes related to screening facilitators were more often mentioned by participants who screened at least once including: (1) Use of a simpler 1-sample fecal test; (2) Convenience of mailings and doing the test at home; (3) Salience of prevention, especially as one got older; and (4) Influence of recommendations from providers, family and friends. Participants had diverse preferences for the number (3 on average) and types (phone, mail, text) of screening reminders. Some participants did not prefer e-mail links to the patient shared electronic health record because of difficulties remembering their password. It was acceptable for a nurse or medical assistant not from their clinic to call them as long as that person was knowledgeable about their records and could communicate with their physician. Participants, especially never screeners, were generally very enthusiastic about the potential option of a CRC screening blood test. CONCLUSION:Future CRC screening programs should be designed to minimize these barriers and maximize facilitators to improve long-term screening adherence. TRIAL REGISTRATION:Primary Funding Agency: The National Cancer Institute of the National Institutes of Health (R01CA121125). Registered at clinicaltrials.gov NCT00697047 .

SUBMITTER: Green BB

PROVIDER: S-EPMC5450259 | biostudies-literature | 2017 May

REPOSITORIES: biostudies-literature

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Reasons for never and intermittent completion of colorectal cancer screening after receiving multiple rounds of mailed fecal tests.

Green Beverly B BB BlueSpruce June J Tuzzio Leah L Vernon Sally W SW Aubree Shay L L Catz Sheryl L SL

BMC public health 20170530 1

<h4>Background</h4>Long-term adherence to colorectal cancer (CRC) screening is particularly important for fecal testing. Some U.S. studies report that only 25% of individuals repeat fecal testing annually. The purpose of this qualitative study was to identify barriers and facilitators reported by patients with suboptimal screening adherence to refine interventions for starting ongoing adherence to CRC screening. We also explored whether participants, particularly never screeners, would be willin ...[more]

PMID: 28558663

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Project description:ImportanceMailing fecal immunochemical test (FIT) kits to patients' homes has been shown to boost colorectal cancer screening rates, but response rates remain limited, and organized programs typically require repeated outreach attempts. Behavioral economics has shown that offering salient financial incentives to patients may increase participation in preventive health.ObjectiveTo compare the impact of different financial incentives for mailed FIT outreach.Design, setting, and participantsThis 4-parallel-arm randomized clinical trial included patients aged 50 to 75 years who had an established primary care clinician, at least 2 visits in the prior 2 years, and were eligible for colorectal cancer screening and not up-to-date. This study was conducted at urban primary care practices at an academic health system from December 2015 to February 2018. Data analysis was conducted from March 2018 to September 2018.InterventionsEligible patients received a letter from their primary care clinician that included a mailed FIT kit and instructions for use. They were randomized in a 1:1:1:1 ratio to receive (1) no financial incentive; (2) an unconditional $10 incentive included with the mailing; (3) a $10 incentive conditional on FIT completion; or (4) a conditional lottery with a 1-in-10 chance of winning $100 after FIT completion.Main outcomes and measuresFecal immunochemical test completion within 2 and 6 months of initial outreach.ResultsA total of 897 participants were randomized, with a median age of 57 years (interquartile range, 52-62 years); 56% were women, and 69% were black. The overall completion rate across all arms was 23.5% at 2 months. The completion rate at 2 months was 26.0% (95% CI, 20.4%-32.3%) in the no incentive arm, 27.2% (95% CI, 21.5%-33.6%) in the unconditional incentive arm, 23.2% (95% CI, 17.9%-29.3%) in the conditional incentive arm, and 17.7% (95% CI, 13.0%-23.3%) in the lottery incentive arm. None of the arms with an incentive were statistically superior to the arm without incentive. The overall FIT completion rate across all arms was 28.9% at 6 months, and there was also no difference by arm. The completion rate at 6 months was 32.7% (95% CI, 26.6%-39.3%) in the no incentive arm, 31.7% (95% CI, 25.7%-38.2%) in the unconditional incentive arm, 26.8% (95% CI, 21.1%-33.1%) in the conditional incentive arm, and 24.3% (95% CI, 18.9%-30.5%) in the lottery incentive arm.Conclusions and relevanceMailed FIT resulted in high colorectal cancer screening response rates in this population, but different forms of financial incentives of the same expected value ($10) did not incrementally increase FIT completion rates. The incentive value may have been too small or financial incentives may not be effective in this context.Trial registrationClinicalTrials.gov Identifier: NCT02594150.

Project description:BackgroundColorectal cancer (CRC) is currently the second leading cause of cancer-related deaths in the United States; however, it is mostly preventable with appropriate screening and is often treatable when detected at early stages. Many patients enrolled in an urban Federally Qualified Health Center (FQHC) clinic were found to be past due for CRC screening.ObjectiveThis study described a quality improvement (QI) project to improve CRC screening rates. This project used bidirectional texting with fotonovela comics and natural language understanding (NLU) to encourage patients to mail fecal immunochemical test (FIT) kits back to the FQHC.MethodsThe FQHC mailed FIT kits to 11,000 unscreened patients in July 2021. Consistent with the usual care, all patients received 2 text messages and a patient navigator call within the first month of mailing. As part of a QI project, 5241 patients who did not return their FIT kit within 3 months, aged 50-75 years, and spoke either English or Spanish were randomized to either usual care (no further intervention) or intervention (4-week texting campaign with a fotonovela comic and remailing kits if requested) groups. The fotonovela was developed to address known barriers to CRC screening. The texting campaign used NLU to respond to patients' texts. A mixed methods evaluation used data from SMS text messages and electronic medical records to understand the impact of the QI project on CRC screening rates. Open-ended text messages were analyzed for themes, and interviews were completed with a convenience sample of patients to understand barriers to screening and impact of the fotonovela.ResultsOf the 2597 participants, 1026 (39.5%) in the intervention group engaged with bidirectional texting. Participating in bidirectional texting was related to language preference (χ22=11.0; P=.004) and age group (χ22=19.0; P<.001). Of the 1026 participants who engaged bidirectionally, 318 (31%) clicked on the fotonovela. Furthermore, 54% (32/59) of the patients clicked on the fotonovela and responded that they loved it, and 36% (21/59) of patients responded that they liked it. The intervention group was more likely to get screened (487/2597, 18.75%) than those in usual care (308/2644, 11.65%; P<.001), and this pattern held, regardless of demographic subgroup (sex, age, screening history, preferred language, and payer type). Interview data (n=16) indicated that the text messages, navigator calls, and fotonovelas were well received and not unduly invasive. Interviewees noted several important barriers to CRC screening and offered suggestions for reducing barriers and increasing screening.ConclusionsTexting using NLU and fotonovela is valuable in increasing CRC screening as observed by the FIT return rate for patients in the intervention group. There were patterns in which patients did not engage bidirectionally; future work should investigate how to ensure that populations are not left out of screening campaigns.

Project description:BackgroundMailed reminders to promote colorectal cancer (CRC) screening by fecal immunochemical testing (FIT) have been shown to be effective in the Medicaid population, in which screening is underused. However, little is known regarding the cost-effectiveness of these interventions, with or without an included FIT kit.MethodsThe authors conducted a cost-effectiveness analysis of a randomized controlled trial that compared the effectiveness of a reminder + FIT intervention versus a reminder-only intervention in increasing FIT screening. The analysis compared the costs per person screened for CRC screening associated with the reminder + FIT versus the reminder-only alternative using a 1-year time horizon. Input data for a cohort of 35,000 unscreened North Carolina Medicaid enrollees ages 52 to 64 years were derived from the trial and microcosting. Inputs and outputs were estimated from 2 perspectives-the Medicaid/state perspective and the health clinic/facility perspective-using probabilistic sensitivity analysis to evaluate uncertainty.ResultsThe anticipated number of CRC screenings, including both FIT and screening colonoscopies, was higher for the reminder + FIT alternative (n = 8131; 23.2%) than for the reminder-only alternative (n = 5533; 15.8%). From the Medicaid/state perspective, the reminder + FIT alternative dominated the reminder-only alternative, with lower costs and higher screening rates. From the health clinic/facility perspective, the reminder + FIT versus the reminder-only alternative resulted in an incremental cost-effectiveness ratio of $116 per person screened.ConclusionsThe reminder + FIT alternative was cost saving per additional Medicaid enrollee screened compared with the reminder-only alternative from the Medicaid/state perspective and likely cost-effective from the health clinic/facility perspective. The results also demonstrate that health departments and state Medicaid programs can efficiently mail FIT kits to large numbers of Medicaid enrollees to increase CRC screening completion.

Dataset Information

Reasons for never and intermittent completion of colorectal cancer screening after receiving multiple rounds of mailed fecal tests.

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Reasons for never and intermittent completion of colorectal cancer screening after receiving multiple rounds of mailed fecal tests.

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